Pelican Health Randolph: Sexual Abuse Investigation Failures - NC
The man who touched her, identified in inspection records as Resident #22, later told inspectors he had done nothing wrong — that he had only patted Resident #27 on the arm twice. Staff who witnessed the aftermath said something different happened. Law enforcement responded to the facility. The responsible party for Resident #27, reached by phone in September, confirmed she had been contacted quickly, that an officer had asked whether she wanted to press charges, and that she had decided not to pursue them. She told inspectors she understood that inappropriate contact could occur in a nursing home setting, that there had been no injury, and that she believed staff had intervened fast enough to keep her family member safe.
The facility's administrator reached a different kind of conclusion. She decided no abuse had occurred at all.
Her reasoning: Resident #22 had scored in the moderate cognitive impairment range on a Brief Interview for Mental Status assessment on the day of the incident. Because he was not cognitively intact, she told inspectors during an interview on September 10, she did not believe what happened met the definition of resident-to-resident abuse. A law enforcement officer who responded that day had reportedly told her that Resident #22 appeared confused and that there was nothing he could do with the accusation. She felt staff had acted appropriately. They had separated the residents immediately, placed Resident #22 on one-to-one supervision while waiting for police, taken his statement, and performed skin checks on Resident #27 and other cognitively impaired residents.
No concerns were noted. No plan of correction was written. The investigation, the administrator said, had not substantiated abuse.
She repeated this position two days later. In a follow-up interview on September 12, she told inspectors again that she did not believe abuse had occurred because both residents were cognitively impaired at the time of the incident. Resident #22 was not in his right mind, she said. His cognition fluctuated on a daily basis.
What the administrator did not explain was how cognitive impairment in the person who did the touching erased the harm to the person who was touched.
Resident #27, according to Nurse #1, required almost total dependent care. She was not ambulatory. She could not move her wheelchair on her own. She was consistently confused. Nurse #1, who knew both residents well and had cared for both of them, told inspectors she had never seen Resident #27 touch anyone inappropriately and did not believe Resident #27 would have initiated any physical contact with Resident #22.
The picture that emerges from the inspection report is of a woman with almost no capacity to protect herself or remove herself from a situation, reached by a man whose own cognition, staff acknowledged, shifted from day to day. On some days he was more intact. On some days he was less. Nobody could say with certainty which kind of day June 9 was for him, though his BIMS score from that date pointed toward moderate impairment. What is in the record is that he later recalled the incident clearly, knew exactly which resident he had been accused of touching, and described his version of events in specific terms.
Resident #22, interviewed on September 8, said he remembered being accused of inappropriately touching a female resident. He named her, in effect, by saying he knew exactly who she was. He said he had only patted her on the arm twice and had done nothing wrong. He also said that since the incident he no longer sat with Resident #27 or the other female residents as he once had, and that he now only spoke to a female resident if she spoke to him first. When inspectors observed him on September 11, he was on the unit, interacting with male residents and staff.
Nurse #1 said she had never witnessed any inappropriate sexual touching between Resident #22 and the female residents. Nurse Aide #8, interviewed separately, said she had not observed or heard of any other inappropriate sexual behavior involving Resident #22 and believed the June 9 incident was isolated. Both noted that his cognition and behavior were variable.
The facility's position, then, rested on two pillars: that Resident #22's cognitive state made him incapable of committing abuse as a matter of definition, and that staff had responded correctly in the immediate aftermath. On the second point, the record does not contradict them. Residents were separated. Supervision was increased. Skin checks were done. Statements were collected.
But the investigation stopped there. No plan of correction was developed. No documentation exists, in what inspectors reviewed, of steps taken to prevent Resident #22 from reaching vulnerable female residents again, beyond his own stated decision to change his behavior. The facility was relying, at least in part, on the word of a man with moderate cognitive impairment that he would govern himself differently going forward.
Federal inspectors who conducted the complaint survey, which concluded September 17, 2025, found the deficiency caused minimal harm or potential for actual harm, and noted that few residents were affected. Those classifications matter for how penalties are assessed and how urgently corrective action is required. They do not address whether the facility's conclusion, that no abuse occurred, was the right one.
The former Director of Nursing, who would have overseen the original investigation, could not be reached. Inspectors noted on September 12 that several attempts to contact her by phone had been unsuccessful.
Resident #27's responsible party told inspectors that during her visits after the incident, the resident had shown no change in her baseline behavior. It was, in the RP's telling, a story with a relatively contained ending: quick staff response, no physical injury documented, a decision not to prosecute, a family that felt the facility had done enough.
What it leaves unresolved is the question the administrator's conclusion sidesteps. A woman who could not walk, could not move herself, and could not reliably communicate was touched in a way that prompted a call to law enforcement and an offer, from police, to pursue criminal charges. The facility investigated, found the man who did it had a low cognitive score that day, and closed the file. Resident #27 remained in the facility. So did Resident #22.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pelican Health Randolph LLC from 2025-09-17 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Pelican Health Randolph LLC in Charlotte, NC was cited for abuse-related violations during a health inspection on September 17, 2025.
Staff who witnessed the aftermath said something different happened.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.