Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Pelican Health Randolph LLC
Charlotte, NC · 100 certified beds · Last Life Safety survey June 27, 2024
CMS Certification Number 345134 · first certified October 1980
Ownership
Independently operated (no chain recorded by CMS) · For profit - Corporation
- Ownership changed October 1, 2019 (change of ownership)to RANDOLPH GARDENS OPCO LLC from CURIS AT CHARLOTTE OPCO LLC
Position within NC
14 citations — more than 71% of the 419 certified nursing homes in NC. Compared within NC rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 3 citations; the earlier surveys in the window averaged 5.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (August 2025 to October 2025), and past the point by which nine in ten NC facilities have been surveyed. This facility’s last Life Safety survey was June 2024. Facilities in NC are typically surveyed 14–16 months after the last one (median 15), measured over 412 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
10 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 14 Life Safety citations above. The Physical Environment Index
- F-0584 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.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
How that compares
Compared with the median facility in NC, and nationally. Surveyors differ markedly between states, so the NC figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 14 |
| Median facility in NC | 9 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| November 22, 2021 | 1 |
| February 28, 2023 | 10 |
| June 27, 2024 | 3 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2024-06-27 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2024-06-27 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2023-02-28 |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 1 | 2023-02-28 |
| K-0271 | Have exits that are accessible at all times. | 1 | 2023-02-28 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2023-02-28 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2023-02-28 |
| K-0919 | Meet requirements for the use of electrical equipment. | 1 | 2023-02-28 |
What the citations cover
- Smoke Deficiencies 7
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Egress Deficiencies 1
- Services Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 7 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Egress Deficiencies | 1 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 27, 2024 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (August 9, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 9, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (August 9, 2024) |
February 28, 2023 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (May 10, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (May 10, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (May 10, 2023) |
| K-0344 | Have an alternate power supply for its alarm system. | Deficient, Provider has date of correction (May 10, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (May 10, 2023) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (May 10, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (May 10, 2023) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (May 10, 2023) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (May 10, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (May 10, 2023) |
November 22, 2021 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 22, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.