Pelican Health Randolph LLC

• Star rating

  The CMS overall star rating changed from 1 of 5 to 3 of 5.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 5 of 5.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 1 of 5.

• Name

  CMS lists a new legal business name for this home.

• Ownership

  CMS no longer lists a chain for this home.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from not rated by CMS to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 5 of 5 to 4 of 5.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to not rated by CMS.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 5 of 5.

• Fine

  CMS changed the fine from April 24, 2024 from $19,663 to $4,017.

CMS lists this as a standard inspection and a complaint inspection.

• Citation F0584. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on October 17, 2025.

  CMS has cited this home for F0584 2 times since 2023.

• Citation F0925. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

  CMS lists it as corrected on October 17, 2025.

• Citation F0558. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Reasonably accommodate the needs and preferences of each resident.

  CMS lists it as corrected on October 17, 2025.

• Citation F0600. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on October 17, 2025.

  CMS has cited this home for F0600 2 times since 2023.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on October 17, 2025.

• Citation F0628. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

  CMS lists it as corrected on October 17, 2025.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on October 17, 2025.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on October 17, 2025.

  CMS has cited this home for F0684 2 times since 2024.

• Citation F0687. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate foot care.

  CMS lists it as corrected on October 17, 2025.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on October 17, 2025.

  CMS has cited this home for F0689 3 times since 2023.

• Citation F0690. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  CMS lists it as corrected on October 17, 2025.

  CMS has cited this home for F0690 2 times since 2024.

• Citation F0693. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on October 17, 2025.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on October 17, 2025.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on October 17, 2025.

  CMS has cited this home for F0880 2 times since 2024.

• Citation F0919. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Make sure that a working call system is available in each resident's bathroom and bathing area.

  CMS lists it as corrected on October 17, 2025.

  CMS has cited this home for F0919 2 times since 2023.

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• Star rating

  The CMS staffing star rating changed from 3 of 5 to 2 of 5.

• Staffing

  Total nurse staffing reported to CMS went from 3.8 to 3.2 hours per resident per day.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.

• Health citation

  CMS removed citation F0867 from the health inspection on March 13, 2024.

• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from not rated by CMS to 2 of 5.

• Fine

  CMS changed the fine from April 24, 2024 from $30,250 to $19,663.

• Star rating

  The CMS health inspection star rating changed from 1 of 5 to 2 of 5.

CMS lists this as a standard inspection.

• Citation F0758. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

  CMS lists it as corrected on July 23, 2024.

  CMS has cited this home for F0758 2 times since 2023.

• Citation F0760. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that residents are free from significant medication errors.

  CMS lists it as corrected on July 23, 2024.

• Citation F0578. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

  CMS lists it as corrected on July 23, 2024.

  CMS has cited this home for F0578 2 times since 2023.

• Citation F0759. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure medication error rates are not 5 percent or greater.

  CMS lists it as corrected on July 23, 2024.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on July 23, 2024.

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CMS lists this as a standard inspection.

• Citation K0321. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  CMS lists it as corrected on August 9, 2024.

  CMS has cited this home for K0321 2 times since 2023.

• Citation K0353. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on August 9, 2024.

• Citation K0918. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on August 9, 2024.

  CMS has cited this home for K0918 2 times since 2021.

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CMS lists this as a complaint inspection.

• Citation F0690. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  CMS lists it as corrected on May 4, 2024.

• Citation F0732. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Post nurse staffing information every day.

  CMS lists it as corrected on May 4, 2024.

• Citation F0657. Severity B: potential for minimal harm, pattern.

  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS lists it as corrected on May 4, 2024.

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CMS lists this as a complaint inspection.

Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

88 of 419 North Carolina homes (21%) got a citation at the immediate jeopardy level in 2024.

• Citation F0684. Severity J: immediate jeopardy, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on January 24, 2024.

• Citation F0689. Severity J: immediate jeopardy, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on January 24, 2024.

• Citation F0554. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Allow residents to self-administer drugs if determined clinically appropriate.

  CMS lists it as corrected on May 4, 2024.

  CMS has cited this home for F0554 2 times since 2023.

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CMS fine of $4,017 on April 24, 2024.

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CMS fine of $7,823 on April 24, 2024.

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CMS fine of $7,823 on April 24, 2024.

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• Fine

  CMS changed the fine from February 28, 2023 from $5,735 to $3,728.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to not rated by CMS.

CMS lists this as a standard inspection.

• Citation F0561. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

  CMS lists it as corrected on June 14, 2023.

• Citation F0584. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on March 24, 2023.

• Citation F0677. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on May 23, 2023.

• Citation F0712. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that the resident and his/her doctor meet face-to-face at all required visits.

  CMS lists it as corrected on May 23, 2023.

• Citation F0725. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  CMS lists it as corrected on May 23, 2023.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on May 23, 2023.

• Citation F0867. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  CMS lists it as corrected on June 14, 2023.

• Citation F0550. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on May 23, 2023.

• Citation F0554. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Allow residents to self-administer drugs if determined clinically appropriate.

  CMS lists it as corrected on May 23, 2023.

• Citation F0578. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

  CMS lists it as corrected on May 23, 2023.

• Citation F0582. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

  CMS lists it as corrected on May 23, 2023.

• Citation F0600. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on May 23, 2023.

• Citation F0636. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

  CMS lists it as corrected on May 23, 2023.

• Citation F0641. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident receives an accurate assessment.

  CMS lists it as corrected on May 23, 2023.

• Citation F0644. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

  CMS lists it as corrected on May 23, 2023.

• Citation F0646. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.

  CMS lists it as corrected on May 23, 2023.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on May 23, 2023.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on May 23, 2023.

• Citation F0758. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

  CMS lists it as corrected on May 23, 2023.

• Citation F0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  CMS lists it as corrected on May 23, 2023.

• Citation F0919. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Make sure that a working call system is available in each resident's bathroom and bathing area.

  CMS lists it as corrected on May 23, 2023.

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CMS lists this as a standard inspection.

• Citation K0271. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have exits that are accessible at all times.

  CMS lists it as corrected on May 10, 2023.

• Citation K0321. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  CMS lists it as corrected on May 10, 2023.

• Citation K0324. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on May 10, 2023.

• Citation K0344. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have an alternate power supply for its alarm system.

  CMS lists it as corrected on May 10, 2023.

• Citation K0345. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have approved installation, maintenance and testing program for fire alarm systems.

  CMS lists it as corrected on May 10, 2023.

• Citation K0351. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Install an approved automatic sprinkler system.

  CMS lists it as corrected on May 10, 2023.

• Citation K0521. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

  CMS lists it as corrected on May 10, 2023.

• Citation K0919. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Meet requirements for the use of electrical equipment.

  CMS lists it as corrected on May 10, 2023.

• Citation K0921. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that testing and maintenance of electrical equipment is performed.

  CMS lists it as corrected on May 10, 2023.

• Citation K0923. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have proper medical gas storage and administration areas.

  CMS lists it as corrected on May 10, 2023.

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CMS lists this as a standard inspection.

• Citation K0918. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on December 22, 2021.

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