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Inspection visit

Fire Safety inspection

Pelican Health Randolph LLCCMS #34513410 citations on this visit
10 citations recorded

Citations

10 citations recorded*CMS

This is a Fire Safety survey. CMS cites these findings under the Life Safety Code and Emergency Preparedness rules, a separate set from the health (F-tag) deficiencies. The codes and grading differ, so these do not link to the health violation pages.

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0271GeneralS&S Dpotential for harm

    Have exits that are accessible at all times.

  • 0321GeneralS&S Dpotential for harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  • 0324GeneralS&S Dpotential for harm

    Provide properly protected cooking facilities.

  • 0344GeneralS&S Dpotential for harm

    Have an alternate power supply for its alarm system.

  • 0345GeneralS&S Dpotential for harm

    Have approved installation, maintenance and testing program for fire alarm systems.

  • 0351GeneralS&S Dpotential for harm

    Install an approved automatic sprinkler system.

  • 0521GeneralS&S Dpotential for harm

    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

  • 0919GeneralS&S Dpotential for harm

    Meet requirements for the use of electrical equipment.

  • 0921GeneralS&S Dpotential for harm

    Ensure that testing and maintenance of electrical equipment is performed.

  • 0923GeneralS&S Dpotential for harm

    Have proper medical gas storage and administration areas.

FAQ · About this visit

Common questions about this visit

What happened during the February 28, 2023 survey of Pelican Health Randolph LLC?

This was a inspection survey of Pelican Health Randolph LLC on February 28, 2023. The surveyor cited 10 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Pelican Health Randolph LLC on February 28, 2023?

Yes, 10 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Have exits that are accessible at all times."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.