Pelican Health at Charlotte

Inspectors wroteBased on record review and resident and staff interviews, the facility failed to treat Resident #1 with dignity and respect when staff engaged in a verbal argument with the resident utilizing profanity and yelling at the resident. The resident reported she felt angry with the way staff treated her. This deficient practice affected 1 of 1 resident reviewed for dignity (Resident #1).

Inspectors wroteBased on observations, record review and interviews with the resident, staff, Responsible Party (RP), Wound Nurse Practitioner, and Medical Director, failed to recognize the severity of the injury, the extent of bleeding, and the resident's increased risk for bleeding due to her daily anticoagulant medication (helps prevent blood from forming clots). On 01/20/26 Nurse Aide #1 pulled Resident #25 backwards alongside the bed hitting the Resident's lower left leg against the corner of the footboard. Resident #25's footboard was damaged, and the outer layer of protective laminate was gone, and pressboard was exposed (pressboard is a dense, stiff engineered material). Resident #25 immediately cried out in pain, and her lower left leg was bleeding. Resident #25 reported a pain scale of 10 on a scale of 1 to 10 (0 being no pain and 10 being the worst possible pain. [...]

Inspectors wroteBased on observations, record review, and interviews with the resident, staff, Responsible Party, Wound Nurse Practitioner, and Medical Director, the facility failed to provide care in a safe manner and ensure a resident's environment remained free of an accident hazard for a dependent resident on Eliquis (an anticoagulant medication that prevents blood from clotting). On 01/20/26 Nurse Aide (NA) #1 transferred Resident #25 using a mechanical lift from the bed to the Resident's wheelchair. Nurse Aide #1 proceeded to pull Resident #25 backwards alongside the bed hitting the Resident's lower left leg against the corner of the footboard. Resident #25's footboard was damaged, and the outer layer of protective laminate was gone, and pressboard was exposed (pressboard is a dense, stiff engineered material). Resident #25 immediately cried out in pain, and her lower left leg was bleeding. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to close the trash receptacle door, remove loose garbage, boxes, and debris and failed to prevent standing water from around 1 of 1 trash receptacle and 1 of 1 recycling receptacle located outdoors behind the kitchen. This practice had the potential to impact sanitary conditions and attract pests and rodents.

Inspectors wroteBased on observation, record review and resident and staff interviews, the facility failed to honor a resident's request to return to bed after arrival to the facility from dialysis services. The resident stated to a staff member that waiting for over an hour for assistance to return to bed after dialysis treatment made her feel lightheaded and even more tired. This deficient practice affected 1 of 4 residents reviewed for choices (Resident #22).

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to maintain the footboards on beds in a resident room in good repair (Residents #25 and #27). The deficient practice affected 1 of 21 rooms on 1 of 4 halls observed for a safe and homelike environment.

Inspectors wroteBased on observations, record reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of range of motion and mobility devices for 1 of 21 sampled residents (Resident #25).

Inspectors wroteBased on observations, record review and resident, staff and Nurse Practitioner interviews, the facility failed to secure medications found at the bedside for 1 of 2 residents reviewed for medication storage (Residents #8).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to keep a fire compression tank clean of debris and keep the floor grout lines clean of greasy residue and food debris. These practices occurred in 1 of 2 food preparation areas and had the potential to affect food served to residents.

Inspectors wroteBased on record reviews, observations and staff interviews, the facility failed to follow their infection control policy and procedures for Enhanced Barrier Precautions (EBP) when Nurse #4 did not wear Personal Protective Equipment (PPE) while providing urinary catheter care for Resident #5. In addition, Nurse Aide (NA) #9 failed to wear PPE while providing urinary catheter care and transferring Resident #33 from wheelchair to bed. These deficiencies occurred for 2 of 10 staff members observed for infection control practices (Nurse #4 and NA #9).

Inspectors wroteBased on observations, record review, and Nurse Practitioner, staff and resident interviews, the facility failed to provide a safe transfer using a mechanical lift for Resident #43. On 3/9/24 Nurse Aide (NA) #1 and NA #2 were transferring Resident #43 with the mechanical lift when a strap that was frayed on the left side of the lift pad broke, and Resident #43 fell approximately 3 feet to the tile floor hitting her head and landing on her right side. Resident #43 was assessed by Nurse #3 and was observed to have a huge hematoma (collection of blood underneath the skin) to the back right side of her head and reported her whole right side hurt. Resident #43 was transported to the Emergency Department (ED) for further evaluation. Computed tomography (CT) scans and x-rays obtained in the ED were negative for fracture or injury. [...]

Inspectors wroteBased on record review, observations, staff interviews and resident interviews the facility failed to accommodate bariatric needs by using the wrong size briefs and not providing fitted sheets for 2 of 2 residents reviewed for accommodation of bariatric needs (Resident #64 and Resident #28).

Inspectors wroteBased on record review, observations, staff interviews and resident interviews, the facility neglected to provide a sufficient quantity of linens and size 2x incontinent briefs for 2 of 2 residents who required bariatric goods (Resident #64 and Resident #28).

Inspectors wroteBased on record review and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours per day, 7 days a week for 29 of 389 days reviewed for sufficient staffing.

Inspectors wrote2. Resident #82 was admitted to the facility on [DATE]. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #82 was discharged to a general hospital. Review of a nursing progress note dated 11/22/24 indicated Resident #82 was discharged home with family. An interview with the MDS Nurse on 1/29/25 at 2:20 PM was conducted. She stated the discharge MDS for Resident #82 dated 11/22/24 should have been coded as discharged home. She explained the Social Worker (SW) had inaccurately coded the MDS. A telephone interview with the SW on 1/30/25 at 10:49 AM revealed she was responsible for coding certain areas of the MDS for all residents, which included the Identification Information section which included discharge status. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to develop a comprehensive care plan in the area of Hospice for 1 of 1 resident reviewed for Hospice (Resident #29).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to obtain a physician's order for the use of supplemental oxygen for 1 of 3 residents reviewed for oxygen use (Resident #29).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to follow their infection control policies and procedures for Enhanced Barrier Precautions during high-contact care and hand hygiene when Nurse #1 performed wound care for a resident with a full-thickness wound without wearing a gown and failed to perform hand hygiene after removing a soiled dressing, cleaning a wound, and before applying a new wound dressing for Resident #20. The deficient practice occurred for 1 of 1 staff member (Nurse #1) observed during wound care.

Inspectors wroteBased on record review and staff interviews, the facility failed to maintain a record of the daily posted nurse staffing sheets for 472 of 519 days of the period reviewed from September 1, 2023 through January 31, 2025.

Inspectors wroteBased on observation, record reviews and staff interviews, the facility failed to ensure Medication Aide (Agency MA #1) and other nursing staff were trained and competent in cleaning and disinfecting glucometers (blood glucose machine) according to manufacturer recommendations using an Environmental Protection Agency (EPA) approved disinfectant cloth, between resident usage. Agency MA #1 was observed not cleaning and disinfecting a shared glucometer between use with three residents (Resident #28, Resident #30, and Resident #57). Interviews with Nurse #2, Nurse #6 and Nurse #10 revealed each nurse was unable to describe glucometer disinfection procedures. This deficient practice involved four of four nursing staff. [...]

Inspectors wroteBased on observations, record reviews, staff, Nurse Practitioner #1, Medical Director, and Local Health Department Nurse interviews, the facility failed to clean and disinfect a glucometer used for more than one resident (blood glucose meter) according to manufacturer's recommendations using an Environmental Protection Agency (EPA) - approved disinfectant cloth, between resident usage. The risk of spreading bloodborne infections is very serious if the products and procedures are not followed. The facility confirmed there were residents who had bloodborne pathogens. This occurred for 3 of 3 sampled residents who were required to have their blood sugars checked (Resident #28, Resident #30, and Resident #57) and 1 of 1 staff observed performing blood glucose monitoring (MA#1). [...]

Inspectors wroteBased on record reviews and interviews with resident, staff, Pharmacist, Nurse Practitioner (NP #2) and the Medical Director (MD), the facility failed to acquire medications ordered for administration resulting in multiple doses of the prescribed controlled substance medication being missed for 1 of 1 resident reviewed for the provision of pharmaceutical services to meet a residents' needs (Resident #33). As a result of this deficient practice, Resident #33 had to be sent to the emergency department where she required 3 days of treatment for benzodiazepine (class of medications used to treat anxiety) withdrawal with delirium symptoms.

Inspectors wroteBased on observations, record review and staff interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following a recertification and complaint survey conducted on 3/22/22 and a complaint investigation survey on 9/20/22. This was for four repeat deficiencies that were cited in the areas of resident rights/exercise of rights, safe, clean, comfortable and homelike environment, prepare/store/serve food under sanitary conditions, and maintain effective pest control program that were originally cited on 3/22/22 during a recertification and complaint survey, recited on the complaint investigation survey on 9/20/22 and subsequently recited during the recertification and complaint survey completed on 8/29/23. [...]

Inspectors wroteBased on observations, record review, resident and staff interview the facility failed to maintain an effective pest control program as evidenced by pests and droppings observed in common areas, and residents' rooms (Resident #60 and Resident # 12).

Inspectors wroteBased on record review, observations, resident, staff, and Nurse Practitioner interviews, the facility failed to assess the ability of residents to self-administer medications for 4 of 4 sampled residents observed with medications at the bedside (Resident #46, Resident #29, Resident #61, and Resident #49).

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to provide a functional shower chair to accommodate a resident's size so she could go to the shower room to receive a shower for one of two residents reviewed for accommodation on needs (Resident #46).

Inspectors wroteBased on record review, resident interviews and staff interviews the facility failed to resolve group grievances that were brought to resident council meetings for 4 of 10 months reviewed (December 2022, February 2023, April 2023, May 2023.)

Inspectors wroteBased on observations, record review, and interviews with resident and staff, the facility failed to maintain a wheelchair in good repair for 1 of 2 residents reviewed for mobility device (Resident #25), failed to maintain bathrooms in good repair for 2 of 5 bathrooms reviewed (Resident #59 and Resident #25), failed to change a soiled privacy curtain for 1 of 8 rooms reviewed for privacy curtain (room [ROOM NUMBER]), and failed to provide towels/washcloths as needed for showers for 2 of 2 halls (100 Hall and 200 Hall).

Inspectors wroteBased on record reviews and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of discharge (Resident #323), medications (Resident #25), and bladder and bowel (Resident #14, Resident #11, and Resident #47) for 5 of 10 residents whose MDS assessments were reviewed.

Inspectors wroteBased on observation, record review and staff, resident, and Nurse Practitioner interviews the facility failed to secure a resident for transfer using a mechanical sit-to-stand lift according to manufacturer's recommendations resulting in two falls. This was for 1 of 5 residents reviewed for supervision to prevent accidents (Resident #18).

Inspectors wroteBased on observations and staff interviews the facility failed to maintain a clean and sanitary kitchen floor, remove expired food in the dry storage area, remove expired food in 1 in of 4 kitchen refrigerators, Additionally, the facility failed to maintain the kitchen's walk-in freezer free from ice build-up and replace a faulty door seal for 1 of 3 reach-in refrigerators. These practices had the potential to affect food and beverages served to residents. Findings Included: During an initial tour of the kitchen conducted on 08/20/23 the following concerns were identified: a. On 8/20/23 at 10:50 AM an observation of the kitchen's walk-in refrigerator found 1 opened bag of shredded cheese wrapped in plastic wrap without an open or use by date on the package. b. [...]

Inspectors wroteBased on record review, and staff and resident interviews the facility failed to maintain the dignity of a resident when a Nurse Aide yelled out to another staff member in the hallway that Resident #46 needed a full linen change for 1 of 7 residents reviewed for dignity (Resident #46).

Inspectors wroteBased on record review and family and staff interviews the facility failed to provide records and resident information to the receiving hospital for 1 of 1 resident reviewed for hospitalization (Resident #423).

Inspectors wroteBased on record review, staff and resident's interviews, the facility failed to revise care plans for 2 of 5 residents reviewed for care plan revision (Resident #18 and #27). Resident #18's care plan was not revised related to transfer assistance and refusal to wear lift slings. Resident # 27's care plan was not revised to indicate changes to an external catheter system.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to follow the physician order for no straws for 1 of 1 resident (Resident #65) reviewed for professional standards.

Inspectors wroteBased on observations, record review, family and staff interviews, the facility failed to complete daily foot inspections as specified in the plan of care and weekly skin assessments for a resident with a diagnosis of diabetes for 1 of 1 sampled resident (Resident #65). Due to the lack of assessments the facility was not aware the resident had swollen and scabbed toes on his right foot.

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to prevent a urinary catheter bag from touching the floor for 1 of 1 resident (Resident #14) reviewed for urinary catheters.

Inspectors wroteBased on observations, resident, and staff interviews, the facility failed to provide a privacy curtain for 1 of 10 rooms on the 100 hall reviewed for privacy (room [ROOM NUMBER]).

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to post the accurate census on the daily nurse staffing sheet for five of five days of the recertification survey (8/20/23, 8/21/23, 8/22/23, 8/23/23, and 8/24/23).