Pelican Health at Charlotte

In the surveyor’s words

From the most serious findings on record at Pelican Health at Charlotte, in the surveyor’s own words.

• Immediate jeopardy, patternF726Aug 29, 2023

  Based 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. […]

• Immediate jeopardy, patternF880Aug 29, 2023

  Based 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). […]

• Immediate jeopardy, patternF698Sep 20, 2022

  Based on observations, record review and staff, Nephrologist, Nurse Practitioner (NP), and Medical Director interviews, the facility failed to schedule and continue [CONDITION(S)] services for Resident #6. As a result, he missed 3 consecutive [CONDITION(S)] appointments ([DATE], [DATE], [DATE]) and was scheduled for a non-emergent [CONDITION(S)] treatment on [DATE] and died [DATE]. This occurred for 1 of 4 sampled residents reviewed for [CONDITION(S)] (Resident #6). Findings included: Resident #6 was admitted to the facility on [DATE] after a hospitalization for abdominal ascites. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A hospital discharge summary dated [DATE] indicated Resident #6 to continue with [CONDITION(S)]. […]

• Immediate jeopardy, isolatedF684Mar 2, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF689Mar 2, 2026

  Based 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. […]