Pelican Health at Charlotte
2616 East 5th Street · Charlotte, NC · 28204 · 7043335165
120 certified beds For profit - Limited Liability company Chain: Simcha Hyman & Naftali Zanziper
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (2 citations).
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $44,030 in fines in the last 24 months.
- Inspection results have improved across recent cycles.
Red flags
Special Focus Facility candidate
CMS lists this facility as a candidate for its Special Focus program for persistently poor inspection performance.
2 immediate-jeopardy citations in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
Cited under the freedom-from-abuse rule
Cited 1 time under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
69% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 1 of 5 Staffing: 2 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 3.22 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.80 | 0.55–0.75 |
| Weekend hours / resident-day | 2.92 | ≈ weekday level |
| Nursing turnover / year | 69% | median 45% |
| Fines (3-yr window) | 7 · $97,610 |
Inspection citations (41 in the current record)
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Potential for harm · D April 29, 2026 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected May 1, 2026 · Resident Rights
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Immediate jeopardy · J March 2, 2026 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected March 4, 2026 · Quality of Life and Care
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Immediate jeopardy · J March 2, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected March 4, 2026 · Quality of Life and Care
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Potential for harm · D March 2, 2026
Ensure each resident receives an accurate assessment.
Corrected March 4, 2026 · Resident Assessment and Care Planning
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Potential for harm · D March 2, 2026
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.
Corrected March 4, 2026 · Pharmacy Service
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Potential for harm · D March 2, 2026
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected March 4, 2026 · Nutrition and Dietary
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Potential for harm · F March 2, 2026
Dispose of garbage and refuse properly.
Corrected March 4, 2026 · Nutrition and Dietary
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Potential for harm · D March 2, 2026
Provide and implement an infection prevention and control program.
Corrected March 4, 2026 · Infection Control
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Potential for harm · D March 2, 2026 · found via complaint
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected March 4, 2026 · Resident Rights
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Potential for harm · D March 2, 2026 · found via complaint
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.
Corrected March 4, 2026 · Resident Rights
-
Immediate jeopardy · J February 3, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected February 20, 2025 · Quality of Life and Care
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Potential for harm · D February 3, 2025
Ensure each resident receives an accurate assessment.
Corrected February 20, 2025 · Resident Assessment and Care Planning
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Potential for harm · D February 3, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected February 19, 2025 · Resident Assessment and Care Planning
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Potential for harm · E February 3, 2025
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected February 21, 2025 · Nursing and Physician Services
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Potential for harm · E February 3, 2025 · found via complaint
Reasonably accommodate the needs and preferences of each resident.
Corrected February 20, 2025 · Resident Rights
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Potential for harm · E February 3, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected February 20, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D February 3, 2025 · found via complaint
Provide safe and appropriate respiratory care for a resident when needed.
Corrected February 21, 2025 · Quality of Life and Care
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Potential for harm · D February 3, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected February 28, 2025 · Infection Control
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No harm found · C February 3, 2025
Post nurse staffing information every day.
Corrected February 21, 2025 · Nursing and Physician Services
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Immediate jeopardy · K August 29, 2023 · found via complaint
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected September 26, 2023 · Nursing and Physician Services
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Immediate jeopardy · K August 29, 2023 · found via complaint
Provide and implement an infection prevention and control program.
Corrected September 26, 2023 · Infection Control
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Actual harm · G August 29, 2023 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected September 26, 2023 · Pharmacy Service
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Potential for harm · D August 29, 2023 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected September 26, 2023 · Resident Rights
-
Potential for harm · E August 29, 2023 · found via complaint
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected September 26, 2023 · Resident Rights
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Potential for harm · E August 29, 2023 · found via complaint
Reasonably accommodate the needs and preferences of each resident.
Corrected September 26, 2023 · Resident Rights
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| March 2, 2026 | Fine | $13,342 |
| March 2, 2026 | Fine | $13,343 |
| February 3, 2025 | Fine | $17,345 |
| December 11, 2023 | Fine | $7,409 |
| November 20, 2023 | Fine | $1,764 |
| October 30, 2023 | Fine | $3,174 |
| July 21, 2023 | Fine | $41,233 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 345201 · certified since December 22, 1980. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.