Inspection Reports for Pelican Pointe Post Acute Nursing & Rehabilitation
NJ, 08204
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
96% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Notice
Deficiencies: 0
Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice outlines the types of information covered, reasons for use and disclosure of health information, individual rights regarding their health information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Routine
Census: 115
Capacity: 120
Deficiencies: 10
Mar 24, 2025
Visit Reason
A routine recertification/LSC survey was conducted from 03/18/2025 through 03/24/2025 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities. The survey included complaint investigations for multiple complaint numbers.
Findings
The facility was found to have multiple deficiencies including an Immediate Jeopardy (IJ) situation related to failure to provide adequate supervision to a resident with a known history of elopement, resulting in serious harm risk. Other deficiencies involved reasonable accommodations, safe environment, pharmacy services, emergency preparedness, life safety code violations, and maintenance issues. Corrective actions and plans of correction were implemented and verified.
Complaint Details
The visit included complaint investigations for complaint numbers NJ 165588, 166015, 174178, 180316, 183137, 183417, and 183485. The Immediate Jeopardy was related to complaint NJ 180316. The complaints were substantiated as evidenced by findings of deficient practices.
Severity Breakdown
Immediate Jeopardy: 1
Severity D: 3
Severity F: 6
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision to a resident with a known history of elopement, resulting in Immediate Jeopardy. | Immediate Jeopardy |
| Failure to maintain a homelike environment accommodating resident needs and preferences. | Severity D |
| Failure to maintain safe, clean, and comfortable environment including housekeeping and maintenance. | Severity D |
| Failure to maintain required minimum direct care staff-to-resident ratios. | — |
| Failure to ensure medication storage and labeling compliance. | Severity D |
| Failure to ensure emergency preparedness policies and procedures were in place and updated. | Severity F |
| Failure to comply with Life Safety Code requirements including means of egress, exit signage, and door hardware. | Severity F |
| Failure to ensure cooking equipment was protected according to NFPA standards. | Severity F |
| Failure to ensure sprinkler system inspections and maintenance were performed and documented. | Severity F |
| Failure to ensure electrical systems and patient-related electrical equipment were maintained and tested properly. | Severity F |
Report Facts
Census: 115
Total Capacity: 120
Deficiencies cited: 10
Medication carts inspected: 3
Expired culture and sensitivity kits: 7
Lyrica blister packs observed: 7
Oxycodone HCL Oxycontin blister packs observed: 8
Tramadol blister packs observed: 37
Medication vials documented: 38
Licensed Nurse Aides (CNAs) required: 12
Certified Nurse Aides (CNAs) present: 11
Certified Nurse Aides (CNAs) deficient days: 4
Licensed Nurse Aides (CNAs) present: 9
Licensed Nurse Aides (CNAs) deficient days: 5
Licensed Nurse Aides (CNAs) required: 14
Licensed Nurse Aides (CNAs) present: 10
Licensed Nurse Aides (CNAs) required: 13
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 2
Nov 20, 2023
Visit Reason
The inspection was conducted based on Complaint #NJ00169106 to investigate allegations related to medical record documentation and staffing compliance at Pelican Pointe Post Acute Nursing & Rehabilitation.
Findings
The facility was found not in substantial compliance with requirements due to failure to complete neurological evaluations after an unwitnessed fall and inconsistent documentation of Activities of Daily Living (ADL) care for residents. Additionally, the facility failed to maintain the required minimum direct care staff-to-resident ratio on multiple day and overnight shifts.
Complaint Details
Complaint #NJ00169106 was substantiated. The facility was found deficient in medical record documentation and staffing ratios based on the complaint investigation.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to complete neurological evaluations (neuro checks) for a resident who sustained an unwitnessed fall and inconsistent documentation of ADL care provided to residents. | SS=D |
| Failure to maintain the required minimum direct care staff-to-resident ratio for Certified Nursing Assistants (CNAs) on 21 of 28 day shifts and total staff on 2 of 28 overnight shifts. | — |
Report Facts
Census: 103
Sample Size: 3
Deficient CNA staffing day shifts: 21
Deficient total staff overnight shifts: 2
Required CNA to resident ratio day shift: 1
Required direct care staff to resident ratio evening shift: 1
Required direct care staff to resident ratio night shift: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding neurological evaluation protocol after resident fall. | |
| Registered Nurse/Unit Manager (RN/UM) | Interviewed about initiation of neurological evaluations after resident falls. | |
| Licensed Nursing Home Administrator (LNHA) | Interviewed about completion of neurological evaluation documentation. | |
| Director of Nursing (DON) | Interviewed regarding expectations for neurological evaluations and ADL documentation. | |
| Certified Nursing Assistant (CNA) #1 | Interviewed about providing and documenting ADL care. |
Inspection Report
Routine
Census: 90
Capacity: 94
Deficiencies: 18
Jan 30, 2023
Visit Reason
Routine standard survey to assess compliance with federal and state regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including safe environment, medication administration, respiratory care, medication storage, food safety, infection control, and life safety code. Deficiencies were cited in areas such as housekeeping, medication administration outside physician orders, respiratory equipment sanitation, expired and undated medications, kitchen sanitation, PPE use, antibiotic stewardship, staffing ratios, emergency preparedness, fire safety, and smoking regulations.
Severity Breakdown
Level 3: 17
Deficiencies (18)
| Description | Severity |
|---|---|
| Facility failed to maintain a sanitary environment and ensure equipment and furniture were clean and in good repair on Unit A, including stained shower curtains, rusty shower rods, and stained chairs. | Level 3 |
| Failed to follow physician's ordered scale when administering as needed medication for 2 residents. | Level 3 |
| Failed to maintain respiratory equipment in a sanitary manner for 1 resident. | Level 3 |
| Failed to date medication when opened and dispose of expired medications; failed to properly store respiratory medication. | Level 3 |
| Failed to maintain kitchen sanitation including uncovered food items, lack of hairnets, no temperature logs, and undated food items. | Level 3 |
| Failed to ensure personal protective equipment was used appropriately in rooms under COVID-19 precautions. | Level 3 |
| Failed to adequately monitor antibiotic use for one resident. | Level 3 |
| Failed to maintain record of influenza vaccinations for all employees and failed to maintain required minimum direct care staff to resident ratios. | Level 3 |
| Emergency generator plan lacked provisions to maintain fuel supply during an emergency. | Level 3 |
| Exit doors equipped with delayed-egress locking systems lacked required signage and one door did not release properly. | Level 3 |
| Two smoke detectors were installed less than 36 inches from ceiling air diffusers. | Level 3 |
| Failed to complete smoke detection sensitivity test for all smoke detectors. | Level 3 |
| Failed to inspect and maintain sprinkler system properly including discolored sprinkler heads and lack of maintenance records for dry sprinkler air compressor. | Level 3 |
| Corridor doors were impeded from closing by objects or devices attached to doors. | Level 3 |
| Penetrations in smoke barriers were not properly sealed with fire-rated materials. | Level 3 |
| Smoking area lacked metal container with self-closing lid for disposal of cigarette butts. | Level 3 |
| Remote annunciator for emergency power source was located in a non-observable area. | Level 3 |
| Failed to inspect weekly the emergency generator as required. | Level 3 |
Report Facts
Census: 90
Total Capacity: 94
Deficiencies cited: 17
Staffing ratio deficiency: 5
Staffing ratio deficiency: 1
Staffing ratio deficiency: 1
Generator KW: 125
Smoke detectors: 178
Residents potentially affected: 94
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Housekeeping | Named in relation to housekeeping deficiencies and corrective actions | |
| Licensed Practical Nurse #1 | LPN | Named in medication administration deficiency |
| Registered Nurse #1 | RN | Named in medication administration deficiency |
| Director of Nursing | DON | Named in medication administration, infection control, staffing, and emergency preparedness deficiencies |
| Director of Maintenance | Named in fire safety, emergency power, and sprinkler system deficiencies | |
| Food Service Director | FSD | Named in food safety deficiencies |
| Speech Language Therapist | SLT | Named in infection control PPE deficiency |
| Certified Nursing Assistant #1 | CNA | Named in infection control PPE deficiency |
| Unit Manager/Licensed Practical Nurse | UMLPN | Named in antibiotic stewardship deficiency |
| Staffing Coordinator | Named in staffing ratio deficiency |
Inspection Report
Annual Inspection
Census: 56
Deficiencies: 1
Jan 29, 2021
Visit Reason
The inspection was a standard annual survey to assess compliance with 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The facility was found not in substantial compliance due to failure to ensure daily reconciliation of controlled substances in the Automated Medication Dispensing System (AMDS) from 12/12/20 through 1/25/21. The narcotic count was confirmed correct on 1/25/21, but shift count signatures were missing in the Controlled Substances Log.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure daily reconciliation of controlled substances in the Automated Medication Dispensing System (AMDS) from 12/12/20 through 1/25/21, evidenced by missing shift count signatures in the Controlled Substances Log. | SS=E |
Report Facts
Census: 56
Number of narcotics listed in AMDS: 19
Deficiency period: 45
Audit duration: 14
Audit frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Interviewed regarding missing signatures on Controlled Substances Log | |
| Center Nurse Executive (CNE) | Interviewed and confirmed missing shift count signatures and narcotic count accuracy | |
| Director of Nursing (DON) | Mentioned regarding new Controlled Substance Log and shift count expectations | |
| Infection Control Nurse | Assisted CNE in narcotic count verification |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 0
Dec 10, 2020
Visit Reason
The inspection was conducted in response to complaint #NJ 141626 to assess compliance with regulatory requirements.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint #NJ 141626 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 3
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