Pelican Health Randolph Llc

During the facility tour, the Regional Maintenance Director indicated the PTAC unit electrical cords had been replaced recently and the PTAC units were removed from the wall and put back into place.

The PTAC units had a middle, top and bottom screw attachment and after the plugs were replaced, only the middle screws were secured when the units were re-installed.

The Regional Maintenance Director indicated the PTAC unit in room [ROOM NUMBER] was leaning to the point that water was leaking form the unit and that was why there were towels and sheets underneath the PTAC unit.An interview with the Administrator on 9/12/25 at 11:15 AM revealed she expected the PTAC units to be installed correctly in residents' rooms and that the Maintenance staff would make the repairs in the appropriate rooms.

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and could not be understood. A telephone interview on 9/8/2025 at 3:23 PM with Resident #27's

who responded to the call and had been asked if she wished to pursue charges against Resident #22.

contact could occur in the nursing home setting and there had been no injury.

The RP felt the facility staff had intervened quickly and kept Resident #27 safe. Resident #27 had not shown any change in her baseline behavior during RP visits.An interview with Resident #22 on 9/8/2025 at 2:55 PM revealed he recalled the incident when he was accused of inappropriately touching a female resident.

He indicated he knew exactly who the female resident was (Resident #27). Resident #22 stated he did nothing wrong, just patted Resident #27 on the arm twice. He indicated he now only spoke to a female resident if spoken to first. He stated he no longer sat with Resident #27 or the other female residents as he once did.An observation on 9/11/2025 at 11:45 AM revealed Resident #22 on the unit and interacting with other male residents and staff.An interview on 9/9/2025 at 3:59 PM with Nurse #1 revealed she knew Resident #22 well.

Nurse #1 indicated Resident #22's cognition could fluctuate on a daily basis.

She stated she had never witnessed any inappropriate sexual touching between Resident #22 and the female residents.

Nurse #1 reported she also cared for Resident #27.

Nurse #1 stated Resident #27 required almost total dependent care.

She stated staff always kept Resident #27 under close supervision as she was not ambulatory, could not propel herself in her wheelchair and was consistently confused.

Nurse #1 indicated she had never seen Resident #27 touch anyone inappropriately and did not believe Resident #27 would have initiated any physical contact with Resident #22.An interview on 9/10/2025 at 1:03 PM with Nurse Aide (NA) #8 revealed she had not observed or heard of any other inappropriate sexual behavior involving Resident #22. NA #8 stated Resident #22's cognition and behavior did fluctuate from day to day.

She believed the interaction between Resident #22 and Resident #27 was an isolated event. An interview on 9/10/2025 at 4:30 PM with the Administrator indicated Resident #22 was not cognitively intact and his cognition fluctuated often.

She did not feel resident to resident abuse had occurred due to Resident #22 having a BIMS score that indicated he had moderate cognitive impairment on the day of the event.

She stated the responding Law Enforcement Officer had told her Resident #22 was confused and there was nothing he could do with the accusation.

She stated she felt staff had acted appropriately and separated the residents immediately. Resident #22 had been interviewed, his statement taken and placed on one to one supervision while waiting for the police.

Staff had performed skin checks on Resident #27 and other cognitively impaired residents with no concerns noted.

Resident interviews regarding abuse were conducted with cognitively intact residents with no concerns noted.

Staff witness statements were obtained.

The Administrator stated there was not a Plan of Correction as their investigation had not substantiated abuse.A follow up interview on 9/12/2025 at 2:45 PM with the Administrator indicated she felt Resident #22 was not in his right mind when he inappropriately touched Resident #27 on 6/9/2025.

She stated Resident #22's cognition fluctuated on a daily basis.

She stated she did not believe abuse had occurred due to both residents being cognitively impaired at the time of the incident.On 9/12/2025, several attempts to reach the Former Director of Nursing by phone were unsuccessful.

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authorities.

record review and staff interviews, the facility failed to report an allegation of resident to resident

abuse (Resident #27).The findings included:The facility's abuse policy revised on 10/20/2022 indicated all alleged violations involving abuse are reported immediately, but no later than 2 hours after the allegation is made, to APS where state law provides for jurisdiction in long-term care facilities in accordance with State law.Resident #27 was admitted to the facility on [DATE].The 24-hour Initial Allegation Report dated 6/9/2025 at 11:55 AM indicated a Nurse Aide (NA) #7 had notified the Administrator that a male resident (Resident #22) had been observed fondling a female resident (Resident #27).

The State Agency was notified on 6/9/2025 at 12:37 PM.

Local law enforcement was notified on 6/9/2025 at 1:30 PM.

The initial report was signed by the Administrator.The 5 Day Investigation Report dated 6/13/2025 at 12:25 PM indicated the Administrator was notified on 6/9/2025 at 11:55 AM by NA #7 that she had observed Resident #22 sitting in the hallway rubbing Resident #27's breast.

The incident was not reported to the Department of Social Services/APS.

The 5 Day Investigation Report was signed on 6/13/2025 by the Administrator.An interview with the Administrator on 9/12/2025 indicated she did not know she was required to report allegations of abuse to Adult Protective Services or she would have done so.

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bed-hold policies.

record review and staff and Ombudsman interviews, the facility failed to notify the Ombudsman in

The findings included: Resident #88 was admitted to the facility on [DATE]. A nursing note dated 7/22/25 at 10:11 AM stated Resident #88 was discharged from the facility to his home on 7/22/25 at 10:00 AM with his family member.

Education on self-care provided and understanding was verbalized.

A review of Resident #88's electronic medical record (EMR) revealed no transfer or discharge notice was issued to Resident #88. A telephone interview on 9/10/25 at 10:41 AM with the Ombudsman revealed she had not received a transfer or discharge list from the facility since May 2025 and was not familiar with Resident #88's discharge home. A telephone interview on 9/12/25 at 3:36 PM with the former Social Worker (SW) revealed she was employed at the facility from June 2025 to the end of August 2025 and was still in training for her position during that time.

The former SW indicated she did not send notifications of transfers or discharges to the Ombudsman and did not know about this requirement.

The former SW indicated the Administrator handled the details for transfers and discharges in the facility. A telephone interview on 9/15/25 at 3:35 PM with the Administrator revealed the facility currently did not have a SW, but she had the expectation that the facility would communicate with the Ombudsman a list of transfers and discharges.

The Administrator indicated she has since been in contact with the Ombudsman and sent her transfer and discharge lists. A telephone interview on 9/17/25 at 1:13 PM with the former Director of Nursing (DON) indicated that Resident #88 had been at the facility for long term antibiotic treatment, which he completed and had a planned to discharge home.

She indicated the former SW was responsible for communicating information to the Ombudsman regarding all transfers and discharges.

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Pelican Health Randolph LLC 4801 Randolph Road Charlotte, NC 28211

and no one showed up for the appointment or had called to cancel it.

She indicated Resident #97 did

An interview with the facility Transportation Scheduler on 9/15/25 at 1:39 PM revealed he did not schedule appointments for residents but did schedule transportation to appointments. He indicated his process was to look through the facility appointment book daily and make transportation arrangements for residents who had appointments scheduled.

The Transportation Scheduler did not recall Resident #97, did not recall making transportation arrangements for her to attend her appointment on 1/15/25 and did not know why she didn’t get scheduled for transportation.

The Transportation Scheduler indicated that if he saw an appointment in the book with EMS written beside it, he didn’t do anything as he didn’t schedule for EMS transportation and did not know who was supposed to be doing the scheduling for EMS transportation. He further voiced he transported residents to dialysis appointments in the facility van and used contracted transportation services for all other appointments.

An attempt made on 9/16/25 at 11:11 AM to speak with former Social Worker #2 who was employed at the time of the missed appointment on 1/15/25 was unsuccessful.

An interview on 9/17/25 at 11:28 AM with the former Assistant Director of Nursing (ADON) who was the ADON at the time of the missed appointment and the current Director of Nursing revealed she recalled Resident #97 but did not recall any issues with her feeding tube and didn’t know why she was not scheduled for transportation to her appointment.

She indicated the Social Worker would make appointments for residents and write them in the appointment book and the Transportation Scheduler would make the necessary transportation arrangements.

A phone interview with the Administrator on 9/15/25 at 3:46 PM She indicated she was not the administrator at the time of Resident #97’s missed appointment on 1/15/25 but her expectation was residents would have transportation scheduled to not miss appointments.

The Administrator revealed it would have been the Social Worker at the time who scheduled appointments and wrote them in the appointment book.

Attempts to speak with the former Medical Director on 9/12/25 at 11:22 AM and 9/16/25 at 11:40 AM were unsuccessful.

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Pelican Health Randolph LLC 4801 Randolph Road Charlotte, NC 28211

Review of the facility's Discharge summary dated [DATE] at 3:05 PM by the former Social Worker #2 revealed Resident #89 was discharged to an assisted living facility.

There was no documentation about any abnormal skin conditions or wound care orders. A telephone interview was conducted with the former SW #2 on 09/11/2025 at 4:33 PM. SW #2 stated that she did not remember Resident #89.

Review of Resident #89's assisted living facility's progress note entered by a Medication Aide dated 02/25/2025 at 4:46 PM revealed Resident #89 was admitted on [DATE] with an open wound on her left foot.

The assisted living facility was not made aware of the wound and Resident #89's family had not been made aware of the wound.

The Medication Aide no longer worked for the assisted living facility and could not be contacted for interview.

Review of the assisted living facility's physician order dated 02/25/2025 revealed an order for Home Health to evaluate and treat Resident #89's left heel wound.

During an interview with the Family Member on 09/10/2025 at 7:45 AM, the Family Member stated when Resident #89 was discharged from the facility to an assisted living facility on 02/24/2025, the nurse at the assisted living facility observed Resident #89 had an open wound to the back of her left ankle.

The Family Member stated the wound was about the size of a fifty-cent piece with a dark center.

The Family Member also revealed the wound was deep through several layers of skin and there was clear drainage coming from the wound.

The Family Member further explained that Resident #89's sock was stuck to the wound.

The Family Member stated that there was no mention of the left ankle wound in Resident #89's discharge paperwork and the skilled nursing facility had not been treating the wound and had not notified her that Resident #89 had developed a wound while in the facility.

The Family Member stated that the assisted living facility's physician stated to the family member that Resident #89's wound was a diabetic wound.

The Family Member stated that she did not know when the wound developed.

The Family Member also revealed that Resident #89 had broken her left ankle about a year ago and had been fitted with an ankle brace which she still wore occasionally. An interview was conducted with the Executive Director of the assisted living facility on 09/15/2025 at 4:35 PM.

The Executive Director also stated that the nurse that admitted Resident #89 to the assisted living facility was no longer employed with the facility, and she was unable to contact her.

The Executive Director further revealed that Resident #89's medical record revealed that Resident #89 was admitted to the facility on [DATE] with a wound on her left foot and remained in the assisted living facility and home health nursing services provided Resident #89's wound care that was required.

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Pelican Health Randolph LLC 4801 Randolph Road Charlotte, NC 28211

Federal health inspectors cited Pelican Health Randolph LLC in Charlotte, NC for a deficiency under regulatory tag F-F0687 during a standard health inspection conducted on 2025-09-17.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate foot care.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 15 deficiencies cited during this inspection of Pelican Health Randolph LLC.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-17.

attached Resident #5’s mechanical lift sling support to the mechanical lift. NA #1 and NA #2

from side to side to release the wheelchair from the mechanical lift. NA #1 and NA #2 transferred

the base of the mechanical lift.

An interview was conducted on [DATE] at 5:45 PM with NA #5. NA #5 reported while using a mechanical lift and transferring residents, the base of mechanical lift should be widened as needed for the size of the chair and the wheels to the mechanical lift should be locked. NA #5 reported she connected the sling to Resident #5 and guided his legs while NA #2 controlled the lift and did not think to look at the lift to assure the base was in a widen position or if the wheels were locked while connecting the resident to the lift.

A phone interview was conducted on [DATE] at 3:22 PM with NA #2. NA #2 stated the procedure when transferring a resident using a mechanical lift should include widening the base of the mechanical lift, placing the lift around the wheelchair and locking the wheels to the lift. NA #2 reported she could not recall opening the base or locking wheels to the mechanical lift.

An interview was completed on [DATE] at 6:06 PM with the East Unit Manager.

The East Unit Manager stated she recalled pulling Resident #5’s wheelchair from side to side because the mechanical lift was tight around the wheelchair.

The East Unit Manager stated if the base was in widened position, she could have removed the wheelchair with more ease.

The East Unit Manager reported she did not think to widen the base of the mechanical lift or lock the wheels to the mechanical lift at the time.

An interview with the Director of Nursing (DON) on [DATE] at 5:30 PM revealed the staff were just educated on [DATE] regarding Mechanical lift transfers.

The DON stated NA #2, NA #5, and the East Unit Manager should have widened the base and locked the wheels to the mechanical lift when transferring Resident #5 on [DATE] at 11:30 AM.

An interview was conducted on [DATE] at 2:18 pm with the Administrator.

The Administrator stated staff received education about mechanical lifts and transfers upon hire and on an as needed basis.

The Administrator stated she expected staff to follow the policy for mechanical lift transfers.

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should obtain a urinary securement device from Central Supply and apply to Resident #5. An interview

would empty urine bag prior to transferring Resident #5 to avoid extra tension pulling on Resident #5's

tubing and just made sure the urinary catheter tubing was not pulling on Resident #5's urinary opening. An interview with the Director of Nursing (DON) was conducted on 9/11/2025 at 2:40 PM.

The DON reported she began working at the facility in October 2024 and 9/10/2025 was her first day as DON.

The DON stated that the nurse aides should empty the urinary bags when they round every 2 hours and at the end of the shift.

The nurses were expected to follow the medical orders and care plans.

The DON stated that since Resident #5 had an order and care plan for a catheter anchor/securement device, the nurse should have placed the anchor or delegated to a nurse aide to place the anchor on Resident #5. A phone interview with Nurse Practitioner #1 was completed on 9/15/25 at 5:13 pm.

Nurse Practitioner #1 stated Resident #5 was followed by urology for chronic urinary tract infections (UTI) and neurogenic bladder.

Nurse Practitioner stated Resident #5 had not had urinary device dislodgement since she began working with the resident January 2025. A phone interview was completed with the Medical Director on 09/16/2025 at 11:31 AM.

The Medical Director stated that he wrote an order for catheter leg anchor because it was best practice to have a urinary securement device to prevent injury to urethra and prevent the urinary catheter from becoming dislodged when Resident #5 was repositioned.

The Medical Director reported that a full urinary bag would add more tension to the urinary catheter tubing that could add to the potential for trauma and the potential for stagnant urine to backflow into the bladder.

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Pelican Health Randolph LLC 4801 Randolph Road Charlotte, NC 28211

Federal health inspectors cited Pelican Health Randolph LLC in Charlotte, NC for a deficiency under regulatory tag F-F0693 during a standard health inspection conducted on 2025-09-17.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 15 deficiencies cited during this inspection of Pelican Health Randolph LLC.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-17.

Federal health inspectors cited Pelican Health Randolph LLC in Charlotte, NC for a deficiency under regulatory tag F-F0695 during a standard health inspection conducted on 2025-09-17.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide safe and appropriate respiratory care for a resident when needed.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 15 deficiencies cited during this inspection of Pelican Health Randolph LLC.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-17.

wax paper onto the overbed table.

The overbed table had visible spills that had not been cleaned prior

prepared with her two fingers without gloves to clean the inside of Resident #93’s sacral

alginate in the wound and secured it with a bordered foam dressing.

The Wound Nurse then gathered her supplies and trash, doffed her gloves and gown, washed her hands with soap and water and left the resident’s room.

An interview was conducted with Wound Nurse on 09/11/2025 at 3:46 PM.

The Wound Nurse stated that her hands were cleaned with alcohol-based hand sanitizer prior to preparing the wound care supplies.

The Wound Nurse reported she had always prepared her wound cleanser and gauze solution without gloves and that “it had never been a problem in the past”.

The Wound Nurse reported she wore gloves to complete Resident #93’s wound care once she was in the resident’s room.

An interview was conducted on 09/12/2025 at 2:17 PM with the Director of Nursing (DON) who also served as the Infection Preventionist (IP).

The DON reported that she started in October 2024 as IP.

The DON stated that the Wound Nurse should have sanitized her hands and worn gloves when touching wound cleanser solution to clean the residents’ wounds.

An interview with the Administrator on 09/12/2025 at 2:23 PM revealed that she expected the Wound Nurse to follow infection control and clean dressing policies and procedures to prevent the spread of any multidrug-resistant organisms.

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Pelican Health Randolph LLC 4801 Randolph Road Charlotte, NC 28211

Federal health inspectors cited Pelican Health Randolph LLC in Charlotte, NC for a deficiency under regulatory tag F-F0919 during a standard health inspection conducted on 2025-09-17.

Category: Environmental Deficiencies

The facility was found deficient in the following area: Make sure that a working call system is available in each resident's bathroom and bathing area.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 15 deficiencies cited during this inspection of Pelican Health Randolph LLC.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-17.

indicated on each of the two monthly visits he would spray the common areas, kitchen, and office

the next visit. He indicated spraying a room included spraying the bathroom, under beds, dressers,

seals around the PTAC units in almost all the resident rooms that would allow pests to enter the building, so he placed glue traps under the PTAC units. He indicated the seal around the front door was compromised and a door sweep strip affixed to this door would help fix to keep bugs out. He revealed the main pest problems at the facility were palmetto bugs (cockroaches) and water bugs. An interview on 9/11/2025 at 1:58 PM with the Regional Director of Maintenance revealed he had only been assigned to the facility for about two months. He indicated the pest control company came bi-weekly and sprayed half the resident rooms visit and the other resident rooms on the next visit, the common areas, and kitchen were always sprayed every visit. He believed the roach problem was based on bugs coming indoors more as the weather was getting cooler and stated the facility did not have any issues with flies.

The Regional Director of Maintenance revealed there were no fly traps at the front doors because there were a double set of doors that kept flies out. On 9/11/2025 at 2:12 PM an interview with the Maintenance Director revealed he had not seen roaches or flies in the facility.

He indicated each visit the pest control company would spray the common areas, offices, kitchen, and one of the two resident hallways alternating on each visit.

The Maintenance Director revealed he had been talking with management about having an air curtain (fan-powered device that creates an invisible air barrier over a doorway) installed on the front door, but no decision had been made yet. He indicated he was not familiar with the gaps around the PTAC units. An interview on 9/12/2025 at 5:46 PM with the Administrator revealed she had been monitoring pest activity in the facility and was concerned about the effectiveness of their current pest control efforts.

She indicated she planned to assess the services of their current pest control provider and ask what else needed to be done to better control the pests in and around the facility and do something different.