A list of the most recent deficiencies for Pelican Health Randolph LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-05-23 | 2023-06-14 | Y |
| Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid. | Health | 2023-05-23 | 2023-06-14 | Y |
| 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. | Health | 2023-05-23 | 2023-06-14 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-05-23 | 2023-06-14 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-02-28 | 2023-06-14 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-02-28 | 2023-06-14 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-28 | 2023-05-23 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-02-28 | 2023-05-23 | Y |
| 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. | Health | 2023-02-28 | 2023-05-23 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-02-28 | 2023-05-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-28 | 2023-05-23 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-02-28 | 2023-05-23 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-02-28 | 2023-05-23 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-02-28 | 2023-05-23 | Y |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2023-02-28 | 2023-05-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-28 | 2023-05-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-28 | 2023-05-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-28 | 2023-05-23 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-02-28 | 2023-05-23 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-02-28 | 2023-05-23 | Y |
| 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. | Health | 2023-02-28 | 2023-05-23 | Y |
| 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. | Health | 2023-02-28 | 2023-05-23 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-28 | 2023-05-23 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-02-28 | 2023-05-23 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2023-03-28 | 2023-05-10 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-03-28 | 2023-05-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-28 | 2023-05-10 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2023-03-28 | 2023-05-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-28 | 2023-05-10 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-03-28 | 2023-05-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-03-28 | 2023-05-10 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-03-28 | 2023-05-10 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-03-28 | 2023-05-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-28 | 2023-05-10 | N |
| 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. | Health | 2023-02-28 | 2023-03-24 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-11-22 | 2022-02-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-22 | 2022-02-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-22 | 2022-02-24 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-02-17 | 2022-02-24 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-02-17 | 2022-02-24 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-02-17 | 2022-02-24 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-02-17 | 2022-02-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-17 | 2022-02-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-17 | 2022-02-24 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-02-17 | 2022-02-24 | Y |
| Post nurse staffing information every day. | Health | 2022-02-17 | 2022-02-24 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-02-17 | 2022-02-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-17 | 2022-02-24 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-11-22 | 2022-02-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-22 | 2022-02-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-22 | 2022-02-17 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-11-22 | 2022-02-17 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-21 | 2021-12-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-01-15 | 2020-02-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-15 | 2020-02-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-15 | 2020-02-02 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-12-13 | 2020-01-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-13 | 2020-01-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-12-13 | 2020-01-10 | N |
