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Deficiency Records for Pelican Health Randolph LLC

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.

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?
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2024-07-24 2024-08-09 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-07-24 2024-08-09 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2024-07-24 2024-08-09 N
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 2024-06-27 2024-07-23 N
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 2024-06-27 2024-07-23 N
Ensure medication error rates are not 5 percent or greater. Health 2024-06-27 2024-07-23 N
Ensure that residents are free from significant medication errors. Health 2024-06-27 2024-07-23 N
Provide and implement an infection prevention and control program. Health 2024-06-27 2024-07-23 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2024-05-03 2024-05-04 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 2024-05-03 2024-05-04 Y
Post nurse staffing information every day. Health 2024-05-03 2024-05-04 Y
Allow residents to self-administer drugs if determined clinically appropriate. Health 2024-03-13 2024-03-13 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-03-13 2024-03-13 Y
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2024-03-13 2024-03-13 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-03-13 2024-01-24 Y
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
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
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
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

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