Inspection Reports for
Pelican Pointe Post Acute Nursing & Rehabilitation
NJ, 08204
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
12.3 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
137% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
96% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Notice
Deficiencies: 0
Date: 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
Annual Inspection
Deficiencies: 1
Date: Jul 15, 2025
Visit Reason
The inspection was conducted as a standard regulatory survey to assess compliance with care planning and other regulatory requirements at Pelican Pointe Post Acute Nursing & Rehabilitation.
Findings
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #3, specifically failing to include and address the resident's ongoing diarrhea and colitis despite multiple documented episodes and treatments. Interviews with staff confirmed that care plans were not updated to reflect new health issues, contrary to job responsibilities.
Deficiencies (1)
F 0656: The facility failed to develop and implement a complete care plan that meets all the resident's needs, with measurable timetables and actions. Resident #3's care plan did not include focus, goals, or interventions related to the resident's diagnosis of colitis and ongoing diarrhea.
Report Facts
Medication doses: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding Resident #3's ongoing diarrhea and care plan update process. | |
| Unit Manager (UM) #1 | Interviewed and confirmed responsibility for care plan updates and acknowledged care plan deficiencies for Resident #3. | |
| Director of Nursing (DON) | Interviewed and confirmed expectations for care plan updates and acknowledged Resident #3's care plan deficiencies. |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Mar 24, 2025
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations of inadequate resident care, safety hazards, medication management issues, and environmental concerns at Pelican Pointe Post Acute Nursing & Rehabilitation.
Complaint Details
Complaint # NJ 180316 involved a cognitively impaired resident with a history of exit-seeking who eloped on 11/20/2024. The resident was found off premises and returned without injury. The facility failed to provide adequate supervision and had faulty door security systems. Immediate jeopardy was identified and removed after corrective actions were implemented and verified.
Findings
The facility was found deficient in maintaining a homelike environment, ensuring adequate supervision to prevent resident elopement, proper medication management including controlled substances and labeling, and proper disposal of garbage and refuse. Immediate jeopardy was identified related to a resident elopement due to faulty door security systems.
Deficiencies (7)
NJAC 8:39-4.1(a)11: The facility failed to reasonably accommodate the needs and preferences of residents by not extending a resident's bed to prevent discomfort and potential injury.
N.J.A.C. 8:39-31.4(a): The facility failed to maintain a homelike environment that was clean, safe, and sanitary, evidenced by cracked shower flooring, holes in drywall, torn window screens, and damaged walls.
N.J.A.C. 8:39-31.3(a): The facility failed to maintain cleanliness and repair broken furniture and equipment in pantry areas, including black debris on floors, missing cabinet drawers, and dirty microwaves.
NJAC 8:39-27.1(a): The facility failed to provide adequate supervision to a cognitively impaired resident with exit-seeking behavior, resulting in elopement and immediate jeopardy to resident health or safety.
NJAC 8:39-29.7(c): The facility failed to establish a system of records for controlled drugs in sufficient detail to enable accurate reconciliation for dispensing controlled medications.
N.J.A.C. § 8:39-29.4 (a) (g): The facility failed to ensure all drugs and biologicals were labeled properly, specifically by not labeling multi-dose vials with the date they were opened and storing expired medical supplies.
NJAC 8:39-19.7: The facility failed to properly dispose of garbage and refuse, with various items improperly stored outside the facility including empty oxygen tanks, mattresses, and furniture.
Report Facts
Residents reviewed for bed accommodation: 23
Residents reviewed for elopement: 2
BIMS score: 11
BIMS score: 3
Controlled medications count discrepancy: 1
Expired culture kits: 7
Medication carts inspected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Interviewed regarding resident comfort and elopement event |
| Licensed Practical Nurse #1 | LPN | Interviewed regarding bed extension procedure and medication cart inspection |
| Registered Nurse Unit Manager #1 | RN/Unit Manager | Interviewed regarding cleanliness responsibilities and elopement supervision |
| Director of Nursing | DON | Confirmed deficiencies and corrective actions, interviewed about medication policies |
| Maintenance Director | MD | Interviewed regarding facility maintenance, door security, and garbage disposal |
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding door security system and elopement event |
| Certified Nurse Aide #1 | CNA | Provided statement about resident elopement |
| Licensed Practical Nurse #2 | LPN | Provided statement about resident elopement |
Inspection Report
Routine
Census: 115
Capacity: 120
Deficiencies: 10
Date: 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.
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.
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.
Deficiencies (10)
Failure to provide adequate supervision to a resident with a known history of elopement, resulting in Immediate Jeopardy.
Failure to maintain a homelike environment accommodating resident needs and preferences.
Failure to maintain safe, clean, and comfortable environment including housekeeping and maintenance.
Failure to maintain required minimum direct care staff-to-resident ratios.
Failure to ensure medication storage and labeling compliance.
Failure to ensure emergency preparedness policies and procedures were in place and updated.
Failure to comply with Life Safety Code requirements including means of egress, exit signage, and door hardware.
Failure to ensure cooking equipment was protected according to NFPA standards.
Failure to ensure sprinkler system inspections and maintenance were performed and documented.
Failure to ensure electrical systems and patient-related electrical equipment were maintained and tested properly.
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
Deficiencies: 2
Date: Nov 20, 2023
Visit Reason
The inspection was conducted based on complaint #NJ00169106 regarding failure to complete neurological evaluations after an unwitnessed fall and inconsistent documentation of Activities of Daily Living (ADL) care provided to residents.
Complaint Details
Complaint #NJ00169106 was substantiated based on observations, interviews, and record reviews showing failure to complete neuro checks after unwitnessed falls and inconsistent ADL documentation for Residents #1 and #2.
Findings
The facility failed to complete required neuro checks for a resident after unwitnessed falls and did not consistently document ADL care for residents as per facility policies. These deficiencies were identified for two residents during record reviews, observations, and staff interviews.
Deficiencies (2)
F 0842: The facility failed to complete neurological evaluations (neuro checks) for a resident after unwitnessed falls as required by facility policy and regulatory standards.
F 0842: The facility failed to consistently document Activities of Daily Living (ADL) care provided to residents, with multiple missed documentation entries across several dates and shifts.
Report Facts
Dates of missed ADL documentation: Multiple dates in November 2023 with missed ADL documentation for Residents #1 and #2
BIMS scores: 2
BIMS scores: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding neuro checks protocol after resident fall |
| Registered Nurse/Unit Manager | Registered Nurse/Unit Manager | Interviewed about neuro checks initiation after unwitnessed falls |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Interviewed about neuro checks completion and documentation |
| Director of Nursing | Director of Nursing | Interviewed about expectations for neuro checks and ADL documentation |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed about ADL care provision and documentation |
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 2
Date: 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.
Complaint Details
Complaint #NJ00169106 was substantiated. The facility was found deficient in medical record documentation and staffing ratios based on the complaint investigation.
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.
Deficiencies (2)
Failure to complete neurological evaluations (neuro checks) for a resident who sustained an unwitnessed fall and inconsistent documentation of ADL care provided to residents.
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
Annual Inspection
Deficiencies: 7
Date: Jan 30, 2023
Visit Reason
The inspection was conducted as a standard annual survey of Pelican Pointe Post Acute Nursing & Rehabilitation to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including maintaining a sanitary environment, following physician-ordered pain scales for PRN medications, maintaining respiratory equipment sanitation, proper medication storage and labeling, kitchen sanitation, infection control practices related to PPE use, and monitoring antibiotic administration.
Deficiencies (7)
F 0584: The 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 curtain rods, and soiled chairs.
F 0658: The facility failed to follow a physician's ordered pain scale when administering PRN pain medication for 2 of 23 sampled residents, administering opioid pain medication outside prescribed severe pain parameters.
F 0695: The facility failed to maintain respiratory equipment in a sanitary manner for Resident #11, including unprotected nebulizer mask and exposed oxygen tubing.
F 0761: The facility failed to date medications when opened, dispose of expired medications, and properly store respiratory medications, including expired vaccines and undated insulin.
F 0812: The facility failed to maintain kitchen sanitation, including uncovered food items, undated opened food packages, dented cans, and incomplete refrigerator temperature logs.
F 0880: The facility failed to ensure appropriate use of personal protective equipment (PPE) in rooms under COVID-19 precautions, with staff observed not wearing gowns as required.
F 0881: The facility failed to adequately monitor antibiotic use by not administering 1 of 14 prescribed doses of Bactrim to Resident #47.
Report Facts
Residents sampled for pain medication review: 23
Medication doses prescribed: 14
Medication doses administered: 13
Medication storage rooms inspected: 2
Residents surveyed for respiratory care: 2
Inspection Report
Routine
Census: 90
Capacity: 94
Deficiencies: 18
Date: 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.
Deficiencies (18)
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.
Failed to follow physician's ordered scale when administering as needed medication for 2 residents.
Failed to maintain respiratory equipment in a sanitary manner for 1 resident.
Failed to date medication when opened and dispose of expired medications; failed to properly store respiratory medication.
Failed to maintain kitchen sanitation including uncovered food items, lack of hairnets, no temperature logs, and undated food items.
Failed to ensure personal protective equipment was used appropriately in rooms under COVID-19 precautions.
Failed to adequately monitor antibiotic use for one resident.
Failed to maintain record of influenza vaccinations for all employees and failed to maintain required minimum direct care staff to resident ratios.
Emergency generator plan lacked provisions to maintain fuel supply during an emergency.
Exit doors equipped with delayed-egress locking systems lacked required signage and one door did not release properly.
Two smoke detectors were installed less than 36 inches from ceiling air diffusers.
Failed to complete smoke detection sensitivity test for all smoke detectors.
Failed to inspect and maintain sprinkler system properly including discolored sprinkler heads and lack of maintenance records for dry sprinkler air compressor.
Corridor doors were impeded from closing by objects or devices attached to doors.
Penetrations in smoke barriers were not properly sealed with fire-rated materials.
Smoking area lacked metal container with self-closing lid for disposal of cigarette butts.
Remote annunciator for emergency power source was located in a non-observable area.
Failed to inspect weekly the emergency generator as required.
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
Date: 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.
Deficiencies (1)
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.
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
Deficiencies: 1
Date: Jan 29, 2021
Visit Reason
The inspection was conducted to evaluate compliance with pharmaceutical service regulations, specifically the daily reconciliation of controlled substances in the Automated Medication Dispensing System (AMDS).
Findings
The facility failed to ensure daily reconciliation of controlled substances in the AMDS from 12/12/20 through 1/25/21, as evidenced by missing signatures on shift count logs. The Center Nurse Executive confirmed the expectation for daily narcotic counts and verified the current narcotic count was correct.
Deficiencies (1)
F0755: The facility failed to ensure a reconciliation of controlled substances in the Automated Medication Dispensing System was performed daily from 12/12/20 through 1/25/21, as shift count signatures were missing. Nurses did not sign the Controlled Substances Log to indicate daily counts were completed.
Report Facts
Narcotics listed in AMDS: 19
Date range of missing daily reconciliations: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Interviewed regarding missing signatures on Controlled Substances Log | |
| Center Nurse Executive (CNE) | Interviewed and confirmed expectations and verified narcotic counts | |
| Director of Nursing (DON) | Provided information about new Controlled Substance Log | |
| Infection Control Nurse | Assisted in narcotic count verification |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 0
Date: Dec 10, 2020
Visit Reason
The inspection was conducted in response to complaint #NJ 141626 to assess compliance with regulatory requirements.
Complaint Details
Complaint #NJ 141626 was investigated and the facility was found to be in substantial compliance.
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.
Report Facts
Sample size: 3
Viewing
Loading inspection reports...
