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TheVardellReport
Pelican Health Randolph LLC
Skilled nursing facility and nursing facility
4801 Randolph Road
Charlotte, NC 28211
Report
← Pelican Health Randolph LLC, free profile
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The Vardell Report.Pelican Health Randolph LLC
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Charlotte, NC
- Record Period
- 2023–2025
- Source Documents
- 7
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 5 inspections from February 2023 to September 2025, state surveyors documented 47 findings at Pelican Health Randolph LLC; 47 have a recorded correction; CMS lists 3 enforcement actions in the window.
- Inspections
- 5
- 2023–2025, standard and complaint
- Findings
- 47
- Deficiencies cited by state inspectors
- Corrected
- 47
- Of 47 findings, with a recorded correction date
- Penalties
- 3
- 3 fines; payment not published
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 1 | 21 | 0 |
| 2024 | 3 | 11 | 2 |
| 2025 | 1 | 15 | 0 |
| 2026 | 0 | 0 | 0 |
What the Record Shows
- 47 of 47 findings have a recorded correction date.
- CMS lists 3 enforcement actions in the window: 3 fines totaling $19,663, their payment not published.
- 3 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, September 17, 2025, recorded 15 findings (most serious: Level E).
What to Ask About
- Accident Hazards and Supervision, Cited in Three Inspections
- Residents Taking Their Own Medication, Cited in Two Inspections
- Treatment Choices and Advance Directives, Cited in Two Inspections
- A Clean, Homelike Setting, Cited in Two Inspections
- Protection From Abuse and Neglect, Cited in Two Inspections
- Quality of Care, Cited in Two Inspections
- Continence and Catheter Care, Cited in Two Inspections
- Psychotropic Medications, Cited in Two Inspections
- Infection Control, Cited in Two Inspections
- Citation F919, Cited in Two Inspections
Report at a Glance
- Facility
- Pelican Health Randolph LLC
- Address
- 4801 Randolph Road, Charlotte, NC 28211
- CMS Certification Number
- 345134
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 100
- Ownership
- For profit - Corporation
- Record Window
- February 28, 2023 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2025
Standard health inspection
15 findings
The same visit included a complaint investigation.
- F584Honor 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.Level ENo actual harm, potential for moreCorrected Oct 17, 2025
- F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level ENo actual harm, potential for moreCorrected Oct 17, 2025
- F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Oct 17, 2025
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Oct 17, 2025
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Oct 17, 2025
- F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level DNo actual harm, potential for moreCorrected Oct 17, 2025
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Oct 17, 2025
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Oct 17, 2025
- F687Provide appropriate foot care.Level DNo actual harm, potential for moreCorrected Oct 17, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Oct 17, 2025
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Oct 17, 2025
- F693Ensure 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.Level DNo actual harm, potential for moreCorrected Oct 17, 2025
- F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Oct 17, 2025
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Oct 17, 2025
- F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level DNo actual harm, potential for moreCorrected Oct 17, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
5 findings
- F758Implement 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.Level ENo actual harm, potential for moreCorrected Jul 23, 2024
- F760Ensure that residents are free from significant medication errors.Level ENo actual harm, potential for moreCorrected Jul 23, 2024
- F578Honor 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.Level DNo actual harm, potential for moreCorrected Jul 23, 2024
- F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Jul 23, 2024
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jul 23, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
3 findings
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected May 4, 2024
- F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected May 4, 2024
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level BPotential for minimal harmCorrected May 4, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
3 findings
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level JImmediate jeopardyCorrected Jan 24, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Jan 24, 2024
- F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected May 4, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Standard health inspection
21 findings
- F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level ENo actual harm, potential for moreCorrected Jun 14, 2023
- F584Honor 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.Level ENo actual harm, potential for moreCorrected Mar 24, 2023
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected May 23, 2023
- F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Level ENo actual harm, potential for moreCorrected May 23, 2023
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected May 23, 2023
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected May 23, 2023
- F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level ENo actual harm, potential for moreCorrected Jun 14, 2023
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected May 23, 2023
- F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected May 23, 2023
- F578Honor 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.Level DNo actual harm, potential for moreCorrected May 23, 2023
- F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level DNo actual harm, potential for moreCorrected May 23, 2023
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected May 23, 2023
- F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Level DNo actual harm, potential for moreCorrected May 23, 2023
- F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected May 23, 2023
- F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected May 23, 2023
- F646Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.Level DNo actual harm, potential for moreCorrected May 23, 2023
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected May 23, 2023
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected May 23, 2023
- F758Implement 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.Level DNo actual harm, potential for moreCorrected May 23, 2023
- F761Ensure 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.Level DNo actual harm, potential for moreCorrected May 23, 2023
- F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level DNo actual harm, potential for moreCorrected May 23, 2023
Enforcement Action
Civil money penalty, $4,017 imposed April 24, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 28, 2023, the nearest before the penalty date.
Enforcement Action
Civil money penalty, $7,823 imposed April 24, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 28, 2023, the nearest before the penalty date.
Enforcement Action
Civil money penalty, $7,823 imposed April 24, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 28, 2023, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Accident Hazards and Supervision, Cited in Three Inspections
Inspectors cited F689 in February 2023, April 2024 and September 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242425F689 across all 5 inspections, oldest to newest - 2
Residents Taking Their Own Medication, Cited in Two Inspections
Inspectors cited F554 in February 2023 and April 2024. This citation covers whether a resident who keeps and takes their own medication has been assessed as safe to do so. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242425F554 across all 5 inspections, oldest to newest - 3
Treatment Choices and Advance Directives, Cited in Two Inspections
Inspectors cited F578 in February 2023 and June 2024. This citation covers residents’ right to accept or refuse treatment and to make an advance directive. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242425F578 across all 5 inspections, oldest to newest - 4
A Clean, Homelike Setting, Cited in Two Inspections
Inspectors cited F584 in February 2023 and September 2025. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242425F584 across all 5 inspections, oldest to newest - 5
Protection From Abuse and Neglect, Cited in Two Inspections
Inspectors cited F600 in February 2023 and September 2025. This citation covers whether residents are protected from abuse and neglect by anyone. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242425F600 across all 5 inspections, oldest to newest - 6
Quality of Care, Cited in Two Inspections
Inspectors cited F684 in April 2024 and September 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242425F684 across all 5 inspections, oldest to newest - 7
Continence and Catheter Care, Cited in Two Inspections
Inspectors cited F690 in May 2024 and September 2025. This citation covers continence care, catheter care and preventing urinary tract infections. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242425F690 across all 5 inspections, oldest to newest - 8
Psychotropic Medications, Cited in Two Inspections
Inspectors cited F758 in February 2023 and June 2024. This citation covers how psychotropic drugs are used, including dose reductions and limits on as-needed orders. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242425F758 across all 5 inspections, oldest to newest - 9
Infection Control, Cited in Two Inspections
Inspectors cited F880 in June 2024 and September 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242425F880 across all 5 inspections, oldest to newest - 10
Citation F919, Cited in Two Inspections
Inspectors cited F919 in February 2023 and September 2025. The agency describes it this way: Make sure that a working call system is available in each resident's bathroom and bathing area. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242425F919 across all 5 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in three inspections, most seriously at level J.
- 02
How do you decide whether a resident may keep and take their own medications?
Residents Taking Their Own Medication: cited in two inspections, most seriously at level D.
- 03
How are a resident’s advance directive and treatment wishes recorded and shared with every shift?
Treatment Choices and Advance Directives: cited in two inspections, most seriously at level D.
- 04
What was done about the cleanliness citation, and how are rooms and shared spaces checked now?
A Clean, Homelike Setting: cited in two inspections, most seriously at level E.
- 05
What happened after the abuse or neglect citation, and what changed in training or supervision?
Protection From Abuse and Neglect: cited in two inspections, most seriously at level D.
- 06
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in two inspections, most seriously at level J.
- 07
How is continence care scheduled, and how do you prevent urinary infections?
Continence and Catheter Care: cited in two inspections, most seriously at level D.
- 08
How many residents take psychotropic medications, and how often are doses reviewed for reduction?
Psychotropic Medications: cited in two inspections, most seriously at level E.
- 09
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in two inspections, most seriously at level D.
- 10
What changed after F919 was cited, and how do you check it now?
Citation F919: cited in two inspections, most seriously at level D.
- 11
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
Insufficient nursing staff was cited in February 2023.
- 12
What led to the 2024 fine, and has it been paid?
A $4,017 civil money penalty was imposed April 24, 2024. CMS publishes the fine, not whether it has been paid. The record holds three enforcement actions in the window.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the North Carolina state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
North Carolina state survey agency
Inspection Feb 28, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
North Carolina state survey agency
Inspection Apr 24, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
North Carolina state survey agency
Inspection May 3, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
North Carolina state survey agency
Inspection Jun 27, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
North Carolina state survey agency
Inspection Sep 17, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 345134
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowFebruary 28, 2023 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before February 2023 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
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