Pelican Health At Charlotte

F-F558.

Based on record review, observations, staff interviews and resident interviews the facility failed to accommodate bariatric needs by using the wrong size briefs and not providing fitted sheets for 2 of 2 residents reviewed for accommodation of bariatric needs (Resident #64 and Resident #28).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 19 345201 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345201 B. Wing 02/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pelican Health at Charlotte 2616 East 5th Street Charlotte, NC 28204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49160 potential for actual harm Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set Residents Affected - Few (MDS) assessment in the areas of functional abilities (Resident #76) and discharge status (Resident #82) for 2 of 2 residents reviewed for accuracy of assessments.

The findings included:

1. Resident #76 was admitted to the facility 8/15/24 with diagnoses including right tibia fracture, muscle weakness and cognitive communication deficit.

A review of the weekly nursing summary dated 10/26/24 completed by Nurse #5 revealed Resident #76 was totally dependent on staff for transfers.

The quarterly Minimum Data Set (MDS) dated [DATE REDACTED] indicated Resident #76 required substantial to maximal assistance with transfers.

The care plan dated 11/26/24 revealed Resident #76 had a problem area related to activities of daily living self-care performance deficit. The intervention was to provide substantial to maximal assistance with transfers but did not include the use of a mechanical lift.

A phone interview was conducted with Nurse #5 on 1/31/25 at 8:46 AM indicated she was the primary nurse that worked with Resident #76 on 1st shift (7AM - 7PM). Nurse #5 stated since Resident #76 was admitted to

the facility she was dependent on staff for transfers and required the use of a mechanical lift.

A phone interview conducted with the MDS Nurse on 1/31/25 at 9:10 AM revealed when completing a resident MDS assessment she pulled information from the point of care which provided the NAs documentation of the level of assistance a resident required to complete activities of daily living (ADL). The MDS Nurse revealed she also interviewed direct care staff to verify the resident's level of functioning. She indicated she was unable to pull up the point of care information used to complete Resident #76's MDS dated [DATE REDACTED] and did not recall if she interviewed the direct care staff concerning her transfer status. She stated if a resident was transferred with a mechanical lift, the transfer status should be coded as dependent

on the MDS. The MDS Nurse revealed she was unsure why she did not code Resident #76's transfer status as dependent.

A phone interview with the Director of Nursing on 1/31/25 at 11:21 AM indicated a resident that was transferred with a mechanical lift was dependent on staff for transfers and the transfer status should be coded as dependent on the MDS assessment.

49366

2. Resident #82 was admitted to the facility on [DATE REDACTED].

Review of the discharge Minimum Data Set (MDS) assessment dated [DATE REDACTED] indicated Resident #82 was discharged to a general hospital.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 19 345201 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345201 B. Wing 02/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pelican Health at Charlotte 2616 East 5th Street Charlotte, NC 28204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Review of a nursing progress note dated 11/22/24 indicated Resident #82 was discharged home with family.

Level of Harm - Minimal harm or An interview with the MDS Nurse on 1/29/25 at 2:20 PM was conducted. She stated the discharge MDS for potential for actual harm Resident #82 dated 11/22/24 should have been coded as discharged home. She explained the Social Worker (SW) had inaccurately coded the MDS. Residents Affected - Few

A telephone interview with the SW on 1/30/25 at 10:49 AM revealed she was responsible for coding certain areas of the MDS for all residents, which included the Identification Information section which included discharge status.

An interview with the Director of Nursing (DON) on 1/29/25 at 4:35 PM revealed residents' discharge MDS should accurately reflect their discharge location and the MDS Nurse should update the MDS.

During an interview with the Administrator on 1/29/25 at 5:16 PM he indicated the MDS should be completed accurately.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 19 345201 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345201 B. Wing 02/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pelican Health at Charlotte 2616 East 5th Street Charlotte, NC 28204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40476

Residents Affected - Few Based on record review and staff interviews, the facility failed to develop a comprehensive care plan in the area of Hospice for 1 of 1 resident reviewed for Hospice (Resident #29).

The findings included:

Resident #29 was admitted to the facility on [DATE REDACTED] with diagnoses which included chronic obstructive pulmonary disease (COPD, lung disease that makes it difficult to breathe) and respiratory failure.

Review of a significant change in status Minimum Data Set (MDS) dated [DATE REDACTED] revealed Resident #29 was cognitively intact and received hospice services.

A review of Resident #29's comprehensive care plan did not reveal a care plan in the area of Hospice.

In an interview with the MDS Nurse on 01/28/25 at 1:51 PM revealed she looked for Resident #29's Hospice care plan in her record and stated she did not have one. She stated she was responsible for completing the comprehensive care plan and missing the Hospice care plan was an oversight.

An interview with the Director of Nursing (DON) on 01/28/25 at 1:53 PM revealed the MDS nurse was ultimately responsible for developing comprehensive care plans. She was unaware Resident #29 did not have a care plan to address Hospice services.

An interview with the Administrator was conducted on 01/29/25 at 4:45 PM. The Administrator stated he was not aware Resident #29 did not have a Hospice care plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 19 345201 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345201 B. Wing 02/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pelican Health at Charlotte 2616 East 5th Street Charlotte, NC 28204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Immediate jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49160 safety Based on observations, record review, and Nurse Practitioner, staff and resident interviews, the facility failed Residents Affected - Few to provide a safe transfer using a mechanical lift for Resident #43. On 3/9/24 Nurse Aide (NA) #1 and NA #2 were transferring Resident #43 with the mechanical lift when a strap that was frayed on the left side of the lift pad broke, and Resident #43 fell approximately 3 feet to the tile floor hitting her head and landing on her right side. Resident #43 was assessed by Nurse #3 and was observed to have a huge hematoma (collection of blood underneath the skin) to the back right side of her head and reported her whole right side hurt. Resident #43 was transported to the Emergency Department (ED) for further evaluation. Computed tomography (CT) scans and x-rays obtained in the ED were negative for fracture or injury. While in the ED Resident #43 experienced acute respiratory insufficiency related to rib pain and/or narcotic administration. Resident #43 returned to the facility on [DATE REDACTED]. Resident #43 was not receiving an anticoagulant (blood thinner). Most recently on 1/15/25 Resident #43 was transferred with the mechanical lift for a shower and suffered a panic attack because she was scared of the mechanical lift. There was a high likelihood of a serious adverse outcome or injury when one of the straps on the lift pad broke when Resident #43 was being transferred with

the mechanical lift. Additionally, the facility failed to secure the mechanical lift brake when transferring Resident #76. This deficient practice occurred for 2 of 6 residents (Resident #43 and Resident #76) reviewed for accidents.

Immediate jeopardy began on 3/09/24 when Resident #43 was transferred using a mechanical lift and fell to

the floor when the strap on the lift pad broke. Immediate jeopardy was removed on 3/10/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective.

Example #2 is being cited a scope and severity of D.

The findings included:

1. A review of the manufacturer's instruction manual for the mechanical lift provided by the facility read in part: The operator shall inspect the mechanical lift before each use checking all bolts for tightness, checking

the sling hardware, making sure all lift parts are in place and checking the lift sling for any wear.

Resident #43 was admitted to the facility on [DATE REDACTED] with diagnoses including type 2 diabetes, chronic kidney disease and muscle weakness.

The quarterly Minimum Data Set (MDS) dated [DATE REDACTED] indicated Resident #43 was cognitively intact and dependent on staff for transfers.

The care plan dated 2/06/24 revealed Resident #43 had a problem area related to activities of daily living self-care performance deficit and the intervention was to use a mechanical lift and two-person assistance for transfers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 19 345201 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345201 B. Wing 02/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pelican Health at Charlotte 2616 East 5th Street Charlotte, NC 28204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 A review of the facility incident report dated 3/09/24 at 3:34 PM written by Nurse #3 revealed Resident #43 was being transferred with the mechanical lift when one of the left side straps on the lift pad snapped in half Level of Harm - Immediate and Resident #43 flipped out of the lift pad and landed on the floor. Resident #43 was observed lying on the jeopardy to resident health or floor at the base of the mechanical lift, had a blank stare and was only responding to painful stimuli for safety approximately 1 minute. Resident #43 reported hitting her head and was complaining of pain to her whole right side. Resident #43 was assessed for injury and noted to have a huge hematoma to the back right side Residents Affected - Few of her head. Nurse #1 called Emergency Medical Services (EMS), notified the Nurse Practitioner (NP) and Resident Representative (RR), and Resident #43 was transferred to the ED for further evaluation.

A review of NA #1's statement dated 3/11/24 indicated on 3/09/24 NA #2 assisted her with transferring Resident #43 to a shower chair. The 4 straps on the lift sling were secured to the hooks on the mechanical lift. During the transfer one of the sling straps broke and Resident #43 fell to the floor hitting her head and landing on her right side.

Several attempts were made to call NA #1 were unsuccessful.

A review of NA #2's statement dated 3/11/24 revealed on 3/09/24 she was assisting NA #1 to transfer Resident #43 to a shower chair using the mechanical lift. When they began lifting Resident #43 one of the straps on the sling broke and she slipped out of the sling, fell to the floor and hit her head.

An interview with NA #2 on 1/29/25 at 8:21 AM revealed on 3/09/24 she assisted NA #1 with transferring Resident #43 to a shower chair using the mechanical lift sometime after lunch. She stated NA #1 placed the lift sling under Resident #43 and hooked the sling straps to the mechanical lift before she entered the room, so she was unsure if NA #1 inspected the sling to ensure it was in good condition. NA #2 indicated they were supposed to check the lift slings before every use to make sure the sling was in good condition and the straps were not frayed or torn. NA #2 revealed when they were lifting Resident #43 from the bed one of the straps on the lift sling snapped and Resident #43 slid out of the sling and fell approximately 3 feet to the floor hitting her head. She indicated they immediately called out for help, Nurse #3 responded and assessed Resident #43 for injury. NA #2 stated she did not recall which strap on the lift sling broke nor did she look at

the sling following the incident.

A review of the Nurse Practitioner note dated 3/09/24 indicated Resident #43 fell to the floor from approximately 3 feet hitting her head and landing on her right side. Nurse #3 reported Resident #43 had a blank stare for one minute and was complaining of head pain and pain to her right side. EMS was called and Resident #43 was sent to the ED for further evaluation.

A review of the hospital records revealed Resident #43 was evaluated in the ED on 3/09/24 due to falling from a mechanical lift and was complaining of pain to her head, right leg and hip. Computed tomography (CT) scans of the head, chest and spine were obtained as well as x-rays of the pelvis, right leg and hip. The CT scan results showed no acute trauma, and the x-rays were negative for fractures. Resident #43 experienced acute respiratory insufficiency while in the ED, suspected to be related to rib pain and/or narcotic administration. Resident #43 was admitted to the hospital on 3/09/24 for observation and discharged back to the facility on [DATE REDACTED] with no new orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 19 345201 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345201 B. Wing 02/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pelican Health at Charlotte 2616 East 5th Street Charlotte, NC 28204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 An interview conducted with Resident #43 on 1/29/25 at 4:30 PM revealed she did not recall the date, but

during a transfer with the mechanical lift from her bed to the shower chair a strap on the lift sling broke and Level of Harm - Immediate she fell to the floor. She indicated she fell left out of the sling, flipped as she fell to the floor landing on her jeopardy to resident health or right side and hitting her head. Resident #43 indicated her head and whole right side hurt and the nurse safety responded and called EMS. She revealed she was transferred to the ED for further evaluation but did not have any injuries or fractures. Resident #43 stated she had to use the mechanical lift to be transferred to a Residents Affected - Few shower chair and only received a few showers since the incident because she was scared to use the mechanical lift. She stated staff were giving her bed baths, but she really enjoyed taking a shower once or twice a week. Resident #43 indicated the few times she received a shower and was transferred with the mechanical lift she had a panic attack.

An interview conducted with Nurse #3 on 1/29/25 at 9:54 AM indicated she was assigned to Resident #43 on 3/09/24. She revealed she heard NA #1 and NA #2 yelling for help and responded to Resident #43's room and observed her lying on the floor. She stated NA #1 and NA #2 reported they were using the mechanical lift to transfer Resident #43 when one of the straps on the lift sling snapped and Resident #43 fell to the floor and hit her head. Nurse #3 revealed she assessed Resident #43 but did not recall if she had any visible injuries. She stated because Resident #43 hit her head she immediately called EMS, notified the NP and Resident #43 was transferred to the ED for further evaluation. Nurse #3 revealed she did not recall which of

the 4 straps on the lift sling broke, but she observed the sling after the incident and the broken strap was frayed which caused it to rip in half.

An interview conducted with the NP on 1/30/25 at 12:47 PM revealed she was notified by Nurse #3 that Resident #43 had a fall to the floor from approximately 3 feet and hit her head. The NP stated Resident #43 was transferred to the ED for further evaluation. She indicated CT scans and x-rays obtained in the ED were negative for acute injury or fractures. The NP revealed she was not immediately aware that Resident #43 fell

during a transfer with the mechanical lift, however that would not have changed the course of treatment. She revealed when a resident falls and hits their head they were at risk for suffering injuries including a concussion or brain bleeding and standard protocol was to transfer them to the ED for further evaluation. The NP stated she could not comment on the safety measures that staff should take when using a mechanical lift to transfer a resident.

An attempt was made to call the Former Director of Nursing, but the phone number was no longer in service.

An interview with the Former Director of Maintenance on 1/31/25 at 3:45 PM revealed he inspected all the mechanical lifts and lift slings once a month to ensure they were in good repair. He stated the nursing staff were responsible for inspecting the lift slings before every use. He stated he was aware of the incident on 3/09/24 involving Resident #43 falling from the mechanical lift due to a strap on the lift sling breaking. The Director of Maintenance indicated he did not recall observing any lift slings during his monthly inspections prior to the incident on 3/09/24 that were damaged or had frayed or torn straps.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 19 345201 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345201 B. Wing 02/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pelican Health at Charlotte 2616 East 5th Street Charlotte, NC 28204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 An interview was conducted with the Former Administrator on 1/29/25 at 12:58 PM. He stated on 3/09/24 he was notified that NA #1 and NA #2 were using a mechanical lift to transfer Resident #43 when one of the Level of Harm - Immediate straps on the lift sling broke and Resident #43 fell to the floor. He revealed he initiated an investigation that jeopardy to resident health or day and determined the lift sling that NA #1 used to transfer Resident #43 was damaged and she did not safety inspect it prior to use. The Former Administrator indicated when staff were using the mechanical lift to transfer a resident, they should inspect the lift sling prior to every use for damage and ensure it was in good Residents Affected - Few repair.

The Administrator was notified of immediate jeopardy on 1/29/25 at 6:00 PM.

The facility provided the following immediate jeopardy removal plan:

Identify those recipients who have suffered or are likely to suffer a serious adverse outcome as a result of the noncompliance:

On 03/09/2024, Resident #43 experienced a fall during a transfer using a mechanical lift. The loop on the sling that connects to the mechanical lift tore resulting in the resident falling to the floor. The Licensed Nurse immediately assessed the resident, found unresponsive to vocal stimulation for about one minute, but responded to painful stimuli. The Licensed Nurse also observed a hematoma on the right side of the back of her head and the resident reported pain to her full right side but denied pain to her neck or back. The Nurse Practitioner was notified of the incident. Resident #43 was subsequently transferred to the hospital via EMS for further evaluation. The hospital evaluation resulted in no fractures reported from the performed imaging and the CT scan of chest, abdomen, pelvis, and spine did not show acute trauma. The resident returned to

the facility on [DATE REDACTED] with no new orders.

On 03/09/2024 the Nurse Aide initially removed the damaged sling from Resident #43's room after the incident occurred and was inspected by the Maintenance Director and Nurse Aide. The sling was immediately thrown in the trash after it was inspected.

Residents at risk of experiencing similar adverse outcomes would include those who rely on mechanical lifts for transfers. A facility-wide audit of all mechanical lift slings was conducted on 03/09/2024 by the facility Maintenance Director with the assistance of a nurse aide. The audit's purpose was to identify residents at risk. The lift slings were thoroughly inspected for rips, tears, and frays. No other lift slings were found to have been defective.

Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be completed:

On 3/9/24 one on one competency assessments were completed for the two nurse aides involved in the incident by Licensed Charge Nurse with emphasis on safety procedures including how to inspect lift slings for rips, tears, and frays, and to immediately remove any slings that are defective. The two nurse aides demonstrated correct usage of the mechanical lift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 19 345201 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345201 B. Wing 02/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pelican Health at Charlotte 2616 East 5th Street Charlotte, NC 28204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On 3/9/24 in-person education was provided to all nurse aides and licensed nurses on duty by the Maintenance Director on proper lift usage and safety procedures including how to inspect lift slings for rips, Level of Harm - Immediate tears, and frays before each use, as well as to immediately remove any slings from use if they are defective jeopardy to resident health or and take them to their immediate supervisor. The in-person training was continued after 3/9/24 for all direct safety care staff, including agency staff, for the rest of the month for those not on duty the day of the incident. All agency staff were in-serviced during facility orientation. The Director of Nursing was responsible for tracking Residents Affected - Few the staff that required education and for providing the education. Staff were not allowed to work until education was completed. New hires, including agency staff, are required to complete education during orientation.

Alleged date of immediate jeopardy removal: 03/10/24

The facility's credible allegation of immediate jeopardy removal was validated on 1/31/25. Observations conducted of the facility's lift slings revealed they were in good repair and there were no slings observed to have frayed straps or other damage. An observation conducted of a resident being transferred with a mechanical lift revealed the NA inspected the lift sling prior to use, it was observed to be in good condition and was used per the manufacturer's instructions. An interview conducted with NA #2 indicated she received education on how to inspect mechanical lifts and lift slings prior to every use for damage, removing damaged equipment immediately from service and then reporting equipment concerns to administration. NA #2 revealed she also received education on performing a safe resident transfer using the mechanical lift and then completed a return demonstration. Interviews conducted with nurses and nurse aides revealed they received education on how to properly inspect mechanical lifts and lift slings prior to every use, immediately removing equipment from service that was damaged, and reporting equipment concerns to administration.

An interview conducted with the Former Director of Maintenance indicated he completed safety inspections of all the mechanical lifts and lift slings, and no concerns were identified. Additionally, it should be noted that

the facility was unable to locate the initial audit completed on 03/09/24 of all of the facility's mechanical lifts nor was the facility able to locate the audit completed on 03/09/24 of all the lift slings that were inspected for rips, tears, and frays. The facility was also unable to provide any ongoing monitoring that had occurred since

the 03/09/24 incident. The facility's immediate jeopardy removal date of 03/10/24 was validated on 1/31/25.

2. A review of the mechanical lift manufacturer's instructions provided by the facility read in part: Operating instructions: Preparation before lifting - widen the base and engage the caster (wheel) brake.

Resident #76 was admitted to the facility 8/15/24 with diagnoses including: Right tibia fracture, muscle weakness and cognitive communication deficit.

The quarterly Minimum Data Set (MDS) dated [DATE REDACTED] indicated Resident #76 was severely cognitively impaired and required substantial to maximal assistance with transfers.

The care plan dated 11/26/24 revealed Resident #76 had a problem area related to activities of daily living self-care performance deficit. The intervention was to provide substantial to maximal assistance with transfers but did not include the use of a mechanical lift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 19 345201 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345201 B. Wing 02/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pelican Health at Charlotte 2616 East 5th Street Charlotte, NC 28204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 An observation was conducted on 1/29/25 at 11:50 AM of Nurse Aide (NA) #2 and NA #3 using the mechanical lift to transfer Resident #76 from her bed to the wheelchair. Nurse Aide (NA) #2 positioned the Level of Harm - Immediate base of the mechanical lift under the bed while NA #3 locked the brake on the bed. NA #2 did not secure the jeopardy to resident health or wheel brake on the base of the mechanical lift. NA #2 was operating the mechanical lift and when she was safety raising Resident #76 from the bed the base of the lift moved and shifted to the right. After Resident #76 was raised from the bed NA #2 moved the mechanical lift from the bed to the wheelchair while NA #3 guided Residents Affected - Few Resident #76 in the lift sling positioning her over the wheelchair. NA #3 made sure the wheelchair brakes were locked and NA #2 lowered Resident #76 into the wheelchair. NA #2 did not secure the wheel brake on

the mechanical lift before lowering Resident #76.

An interview was conducted with NA #3 on 1/29/25 at 3:30 PM. She stated she was assisting NA #2 to transfer Resident #76 with the mechanical lift. NA #3 indicated she was not operating the mechanical lift

during the transfer, and it was the responsibility of the person operating the lift to ensure the wheel brake was secured prior to lifting the resident. NA #3 revealed she did not notice that the brake on the mechanical lift was not secured prior to Resident #76 being lifted from the bed and she was unsure as to why NA #2 did not secure the brake.

A phone interview with NA #2 on 1/30/25 at 1:18 PM revealed when using the mechanical lift to transfer a resident, the wheel brake on the mechanical lift should be secured prior to lifting or lowering the resident. NA #2 stated when she was using the mechanical lift to transfer Resident #76 on 1/29/25 she did not recall that

the wheel brake on the mechanical lift was not secured when she was lifting and lowering Resident #76 and

she thought she had secured the brake.

A phone interview was conducted with the Director of Nursing (DON) on 1/30/25 at 8:40 AM. She stated when staff were transferring a resident with the mechanical lift they should operate the lift per the manufacturer's guidelines. The DON further stated if the manufacturer's guidelines indicated the wheel brake

on the mechanical lift should be secured prior to lifting or lowering the resident then staff should secure the wheel brake accordingly.

A phone interview was conducted with the Administrator on 1/31/25 at 9:30 AM. He stated nursing staff should operate the mechanical lifts per the manufacturer's guidelines including securing the wheel brake on

the mechanical lift prior to lifting or lowering a resident to ensure the resident was transferred safely.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 19 345201 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345201 B. Wing 02/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pelican Health at Charlotte 2616 East 5th Street Charlotte, NC 28204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40476 potential for actual harm Based on observations, record review, and staff interviews, the facility failed to obtain a physician's order for Residents Affected - Few the use of supplemental oxygen for 1 of 3 residents reviewed for oxygen use (Resident #29).

The findings included:

Resident #29 was admitted to the facility on [DATE REDACTED] with diagnoses which included chronic obstructive pulmonary disease (COPD, a lung disease that makes it difficult to breathe) and respiratory failure.

Review of a significant change Minimum Data Set (MDS) dated [DATE REDACTED] revealed Resident #29 was cognitively intact and received oxygen therapy.

Review of Resident #29's physician's orders revealed there were no orders for supplemental oxygen.

An observation and interview was conducted on 01/26/2025 at 12:05 PM with Resident #29. Resident #29 was observed lying in bed with oxygen on at 3.5 liters per minute via nasal canula. She stated 3.5 liters per minute was her normal setting and she had been on supplemental oxygen for over a year.

An observation was conducted on 01/27/2025 at 3:27 PM of Resident #29. Resident #29 was observed lying

in bed with oxygen on at 3.5 liters per minute via nasal canula.

An observation was conducted on 01/28/2025 at 2:08 PM of Resident #29. Resident #29 was observed lying

in bed with oxygen on at 3.5 liters per minute via nasal canula.

An interview was conducted on 01/28/2025 at 1:23 PM with Nurse #2. Nurse #2 stated if a resident was on oxygen, there should be an order in the resident's medical record. Nurse #2 stated Resident #29 had been

on oxygen since admission and stated she was unsure why she did not have an order. Nurse #2 stated Resident #29 should have had an order for oxygen.

An interview was conducted on 01/28/2025 at 1:32 PM with Unit Manger #1. Unit Manager #1 stated if a resident was on oxygen there would be an order in the resident's medical record and would sign off that oxygen was in use on the Medication Administration Record (MAR). Unit Manager #1 stated she was not aware Resident #29 did not have an order for oxygen and stated she should have.

An interview was conducted on 01/28/2025 at 1:53 PM with the Director of Nursing (DON). The DON stated if a resident required oxygen there should be an order in the resident's chart. The DON stated she was not sure why Resident #29 did not have an order for oxygen and stated she should have.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 19 345201 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345201 B. Wing 02/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pelican Health at Charlotte 2616 East 5th Street Charlotte, NC 28204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on

a full time basis. Level of Harm - Minimal harm or potential for actual harm 49160

Residents Affected - Some Based on record review and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours per day, 7 days a week for 29 of 389 days reviewed for sufficient staffing.

The findings included:

Review of the PBJ (Payroll Based Journal) Staffing Data Report Fiscal Year - Quarter 2, 2024 (January 1 - March 31, 2024) revealed the facility had no RN coverage on 1/06/2024, 1/20/2024,1/21/2024, 2/03/2024, 2/04/2024, 2/10/2024, 2/11/2024, 2/17/2024, 2/18/2024, 3/02/2024, 3/10/2024, 3/16/2024 and 3/30/2024.

Review of the PBJ Staffing Data Report Fiscal Year - Quarter 3, 2024 (April 1 - June 30, 2024) revealed the facility had no RN coverage on the following dates: 5/12/2024, 5/18/2024, 6/08/2024 and 6/15/2024.

Review of the PBJ Staffing Data Report Fiscal Year - Quarter 4, 2024 (July 1 - September 31, 2024) revealed the facility had RN coverage for 8 consecutive hours per day, 7 days a week during the report period.

The facility's daily assignment schedules from 10/01/2024 to 1/31/2024 revealed the facility failed to provide 8 hours of RN coverage on the following dates: 10/05/2024, 10/06/2024, 10/20/2024, 10/27/2024, 11/03/2024, 11/16/2024, 11/30/2024, 12/07/2024, 12/08/2024, 12/14/2024, 12/17/2024, and 12/20/2024.

An interview with the Staff Scheduler on 1/31/25 at 3:30 PM indicated he scheduled an RN daily to work at least 8 consecutive hours. He stated if the RN was scheduled to work on a weekday and called out the MDS Coordinator or Wound Care Nurse were able to fill in as the RN on duty. The Staff Scheduler further stated if

the RN scheduled to work on a weekend day called out there was not usually another RN in the building to fill in and they had difficulty finding a replacement. He indicated they were actively working to hire nurses including RNs and currently used three different staffing agencies to fill vacant shifts.

A phone interview was conducted with the Administrator on 1/31/25 at 9:30 AM. He stated the facility came under new ownership 12/16/2024 and they had a corporate recruiter that was working on hiring nursing staff including RNs. He indicated he was unable to provide records that an RN worked on the dates identified both

on the PBJ Staffing Data Reports and the facility's daily assignment schedules that there was no RN coverage. The Administrator stated the facility should have an RN scheduled at least 8 consecutive hours per day, 7 days a week.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 19 345201 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345201 B. Wing 02/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pelican Health at Charlotte 2616 East 5th Street Charlotte, NC 28204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 Post nurse staffing information every day.

Level of Harm - Potential for 49160 minimal harm Based on record review and staff interviews, the facility failed to maintain a record of the daily posted nurse Residents Affected - Many staffing sheets for 472 of 519 days of the period reviewed from September 1, 2023 through January 31, 2025.

The findings included:

The daily nurse staffing sheets for September 2023 revealed no information was available for the days of 9/01/2023 through 9/30/2023.

The daily nurse staffing sheets for October 2023 revealed no information was available for the days of 10/01/2023 through 10/31/2023.

The daily nurse staffing sheets for November 2023 revealed no information was available for the days of 11/01/2023 through 11/30/2023.

The daily nurse staffing sheets for December 2023 revealed no information was available for the days of 12/01/2023 through 12/31/2023.

The daily nurse staffing sheets for January 2024 revealed no information was available for the days of 1/01/2024 through 1/31/2024.

The daily nurse staffing sheets for February 2024 revealed no information was available for the days of 2/01/2024 through 2/29/2024.

The daily nurse staffing sheets for March 2024 revealed no information was available for the days of 3/01/2024 through 3/31/2024.

The daily nurse staffing sheets for April 2024 revealed no information was available for the days of 4/01/2024 through 4/30/2024.

The daily nurse staffing sheets for May 2024 revealed no information was available for the days of 5/01/2024 through 5/31/2024.

The daily nurse staffing sheets for June 2024 revealed no information was available for the days of 6/01/2024 through 6/30/2024.

The daily nurse staffing sheets for July 2024 revealed no information was available for the days of 7/01/2024 through 7/31/2024.

The daily nurse staffing sheets for August 2024 revealed no information was available for the days of 8/01/2024 through 8/31/2024.

The daily nurse staffing sheets for September 2024 revealed no information was available for the days of 9/01/2024 through 9/30/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 19 345201 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345201 B. Wing 02/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pelican Health at Charlotte 2616 East 5th Street Charlotte, NC 28204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 The daily nurse staffing sheets for October 2024 revealed no information was available for the days of 10/01/2024 through 10/31/2024. Level of Harm - Potential for minimal harm The daily nurse staffing sheets for November 2024 revealed no information was available for the days of 11/01/2024 through 11/30/2024. Residents Affected - Many

The daily nurse staffing sheets for December 2024 revealed no information was available for the days of 12/01/2024 through 12/15/2024.

A phone interview with the Scheduler on 1/30/2025 at 8:54 AM indicated he was responsible for completing

the daily posted nurse staffing sheets and maintaining a record of the sheets for 18 months. He stated due to

the facility's ownership changing on 12/16/2024 they did not have access to the posted nurse staffing sheet records prior to that date.

A phone interview with the Administrator on 1/31/2025 at 9:30 AM indicated the facility's ownership changed

on 12/16/2024 and there were no records of the daily posted nurse staffing sheets available prior to that date. He stated records of the daily posted nurse staffing should be maintained for 18 months.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 19 345201 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345201 B. Wing 02/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pelican Health at Charlotte 2616 East 5th Street Charlotte, NC 28204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 40476 potential for actual harm Based on observations, record review, and staff interviews, the facility failed to follow their infection control Residents Affected - Few policies and procedures for Enhanced Barrier Precautions during high-contact care and hand hygiene when Nurse #1 performed wound care for a resident with a full-thickness wound without wearing a gown and failed to perform hand hygiene after removing a soiled dressing, cleaning a wound, and before applying a new wound dressing for Resident #20. The deficient practice occurred for 1 of 1 staff member (Nurse #1) observed during wound care.

The findings included:

The facility's Enhanced Barriers policy approved 03/28/24 revealed it is the policy of this facility to use enhanced barrier precautions (EBP) based on guidance from the Center for Disease Control (CDC). Enhanced barrier precautions refer to the infection control intervention aimed at reducing transmission of multi-resistant organisms (MDROs) through the targeted use of gown and gloves during high-contact resident care activities. High-contact resident care activities requiring EBP include wound care (any skin opening requiring a dressing).

The Hand Hygiene policy last revised July of 2024 revealed staff were to perform hand hygiene before performing dressing care or touching wounds of any kind, after handling dressings, urinals, catheters, bedpans, contaminated tissues, linen, etc. The policy also stated hand hygiene should be performed after removing gloves.

The Clean Dressing Change policy effective July 2024 revealed staff were to complete the following:

- Wash hands and put on clean gloves.

- Place a barrier cloth or pad next to the resident, under the wound to protect the bed and body sites.

- Loosen the tape and remove the existing dressing.

- Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacles.

- Wash hands and put on clean gloves.

- Cleanse the wound as ordered. Pat dry with gauze.

- Wash hands and put on clean gloves.

- Apply topical ointments or creams and dress the wound as ordered.

- Secure dressing. [NAME] with initials and date.

- Discard disposable items and gloves into appropriate trash receptable and wash hands.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 19 345201 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345201 B. Wing 02/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pelican Health at Charlotte 2616 East 5th Street Charlotte, NC 28204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 An observation was conducted on 1/29/2025 at 9:26 AM while Resident #20 received wound care. Nurse #1 was observed entering Resident #20's room without a gown, laying wound supplies on the bedside table and Level of Harm - Minimal harm or applied clean gloves without performing hand hygiene. Nurse #1 removed a soiled dressing from Resident potential for actual harm #20's sacrum and changed gloves without performing hand hygiene. Nurse #1 cleaned the wound on Resident #20's sacrum and placed a clean dressing on the wound. Nurse #1 then removed her gloves and Residents Affected - Few washed her hands prior to exiting Resident #20's room.

An interview was conducted on 1/29/2025 at 9:36 AM with Nurse #1. Nurse #1 stated Resident #20 was not

on Enhanced Barrier Precautions. Nurse #1 stated EBP were used when a resident had an indwelling medical device and was unsure if it was needed for wounds. Nurse #1 stated she did not sanitize or wash her hands between removing the old dressing, cleaning the wound, and placing the new dressing on Resident #20's wound because she had just forgotten and was doing the best that she could. Nurse #1 stated after the surveyor brought the EBP to her attention she then noticed the EBP sign located at the head of the resident's bed on the wall. Nurse #1 stated there should be gowns on the outside of the resident room so she would have known he was on EBP. The interview revealed Nurse #1 typically did not complete wound care in the facility however, the Wound Care Nurse had called out on the date observed and she was asked to complete all dressing changes for the day.

An interview was conducted on 1/29/2025 at 10:25 AM with the Director of Nursing (DON). The DON stated

she served as the Infection Control Nurse for the facility since January 2025. The DON stated staff received education about infection control during orientation and annually. The DON stated when staff performed wound care, they should wash their hands and change gloves before removing the old dressing and then perform hand hygiene and glove changes in between steps. The DON stated Nurse #1 should have changed gloves and performed hand hygiene after she removed the dirty dressing, after cleaning, and before applying

a new dressing. The DON stated residents with a wound, required EBP. The DON stated she was not sure why Resident #20's EBP sign was not located on the resident's door or have gowns outside of the room for staff. The DON stated she was still new to the facility and would be keeping a closer eye on EBP.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 19 345201