Pelican Health Randolph Llc

F 0558

stated she expected staff to ensure each resident had a call bell in reach prior to leaving the room.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pelican Health Randolph LLC

4801 Randolph Road Charlotte, NC 28211

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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observations, residents and staff interviews, the facility failed to fill the gaps around the packaged terminal air conditioners (PTACs) to separate the exterior environment from the interior of the residents' rooms and failed to secure the seal around the PTACs (rooms #108, #110, #135, #151) for 4 of 8 rooms on 3 of 4 halls reviewed for homelike environment. The findings included:a. An observation conducted on 9/12/25 at 9:32 AM in room [ROOM NUMBER] revealed the PTAC unit did not align against the wall and there was an approximately one-inch gap across the top of PTAC unit where the remaining insulation was observed to be

in a crumbled condition. Through the gap daylight from the exterior of the building was visible from the interior of the resident room.b. An observation conducted on 9/12/25 at 9:43 AM in room [ROOM NUMBER] revealed the PTAC unit did not align with the wall across the top of the unit. The PTAC unit stuck out approximately one inch from the wall which created a gap where the resident room was not sealed from the outside. Through the gap daylight from the exterior of the building was visible from the interior of the resident room. c. An observation conducted on 9/12/2025 at 9:48 AM in room [ROOM NUMBER] revealed there was a two-inch gap across the top of the PTAC unit and the wall. The PTAC unit was not aligned with

the wall and the top portion of the unit leaned inwards towards the room. There was a large open area on

the right side of the unit where the unit was not sealed to the wall. There were wet, soiled towels and sheets at the time of the observation with brown stains on them, present underneath the PTAC unit. d. An

observation on 9/12/25 at 9:58 AM in room [ROOM NUMBER] revealed the PTAC unit had a two-inch gap across the top of the unit and the wall. The insulation in the gap was observed to be crumbled as evidenced by smaller pieces of the insulation in the vicinity of main piece of insulation. A second observation of rooms 108, 110, 135, and 151 and facility tour with the Maintenance Director, Regional Maintenance Director, and

the Administrator occurred on 9/12/25 at 10:58 AM. The PTAC unit placement in each resident room remained unchanged from the first observation. The Maintenance Director, Regional Maintenance Director and the Administrator explained they were not aware of the PTAC unit gaps in rooms 108, 110, 135, or 151.

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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pelican Health Randolph LLC

4801 Randolph Road Charlotte, NC 28211

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 0600 Level of Harm - Minimal harm or potential for actual harm

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.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pelican Health Randolph LLC

4801 Randolph Road Charlotte, NC 28211

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and staff interviews, the facility failed to report an allegation of resident to resident sexual abuse to Adult Protective Services (APS) for 1 of 3 residents reviewed for 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 REDACTED].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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pelican Health Randolph LLC

4801 Randolph Road Charlotte, NC 28211

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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

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

the resident's discharge home for 1 of 3 residents reviewed for discharge (Resident #88). The findings included: Resident #88 was admitted to the facility on [DATE REDACTED]. 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pelican Health Randolph LLC

4801 Randolph Road Charlotte, NC 28211

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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

A phone interview on 9/11/25 at 3:42 PM with the appointment scheduler at the gastroenterologist’s office revealed Resident #97 had an appointment on 1/15/25 at 11:00 AM and no one showed up for the appointment or had called to cancel it. She indicated Resident #97 did not have any other appointments scheduled with their office.

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.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pelican Health Randolph LLC

4801 Randolph Road Charlotte, NC 28211

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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 REDACTED] 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pelican Health Randolph LLC

4801 Randolph Road Charlotte, NC 28211

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)

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.

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Resident #5’s mechanical lift sling support to the mechanical lift. NA #1 and NA #2 tried to move the lift to Resident #5’s bed and could not pull the mechanical lift away from Resident #5’s wheelchair. The East Unit Manager maneuvered Resident #5’s wheelchair from side to side to release the wheelchair from the mechanical lift. NA #1 and NA #2 transferred Resident #5 from the mechanical lift to his bed without widening the mechanical lift base or locking the base of the mechanical lift.

An interview was conducted on [DATE REDACTED] 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 REDACTED] 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 REDACTED] 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 REDACTED] at 5:30 PM revealed the staff were just educated

on [DATE REDACTED] 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 REDACTED] at 11:30 AM.

An interview was conducted on [DATE REDACTED] 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.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pelican Health Randolph LLC

4801 Randolph Road Charlotte, NC 28211

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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

securement device to his left leg to secure urinary catheter tubing. An interview was completed with Wound Nurse on 09/11/2025 at 3:46 PM. The Wound Nurse stated she had been assigned to Resident #5 in past and was only assigned to complete Resident #5's wound care for 09/10/2025. The Wound Nurse reported that the assigned nurse for Resident #5 should obtain a urinary securement device from Central Supply and apply to Resident #5. An interview was completed with Nurse Aide (NA) #3 on 09/10/2025 at 3:45 PM.

NA #3 confirmed he was assigned to Resident #5 and reported he would empty urine collection bags

during his rounds every 2 hours and would empty urine bag prior to transferring Resident #5 to avoid extra tension pulling on Resident #5's catheter tubing. NA #3 stated he had not noticed a securement device for Resident #5's catheter 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pelican Health Randolph LLC

4801 Randolph Road Charlotte, NC 28211

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)

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.

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

the room with her supplies on wax paper and laid the supplies on the wax paper onto the overbed table.

The overbed table had visible spills that had not been cleaned prior to placing the supplies on the table. The Wound Nurse washed her hands with soap and water and donned gown and clean gloves and proceeded to use the wound cleanser-soaked gauze she had prepared with her two fingers without gloves to clean the inside of Resident #93’s sacral wound. The Wound Nurse then proceeded to use gauze to dry the wound and to apply the calcium 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.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pelican Health Randolph LLC

4801 Randolph Road Charlotte, NC 28211

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)

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.

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

roaches in numbers too numerous to count. Resident #66 indicated he had seen lots of small bugs near his bed. An interview with the Pest Control Technician on 9/11/25 at 11:16 AM revealed the company he worked for was contracted to provide services at the facility twice a month and when there were call-backs for pest sightings in between those visits. He indicated on each of the two monthly visits he would spray the common areas, kitchen, and office areas and check the rodent bait traps around the exterior of the facility.

He stated he sprayed the resident rooms on the East hallway rooms one visit, and the resident rooms on

the [NAME] hallway the next visit. He indicated spraying a room included spraying the bathroom, under beds, dressers, nightstands, and under the PTAC unit. The Pest Control Technician stated there were gaps

in the 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.

Event ID:

Facility ID:

If continuation sheet