Pelican Pointe Post Acute Nursing & Rehabilitation
3809 Bayshore Road, North Cape May, NJ 08204 · For profit - Limited Liability company · 120 certified beds · (609) 898-0677 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $16,153 in federal fines (most recent 2025-03-24)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- about 25% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.3% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.6% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.5% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.3% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 1.7% | 12.1% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.6% | 2.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.0% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 21.5% | 18.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.1% | 5.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 24.6% | 15.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 13.7% | 12.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.3% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 99.1% | 80.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 23.5% | 24.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 8.6% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.90 | 2.07 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.15 | 1.11 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
42.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 142 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 91.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 83 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.24 therapist hours per resident per day in 2026Q1 — more than 31% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 15% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 42.1%CMS range 33.0–51.4 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 13.6%CMS range 9.9–17.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 91.6% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 89.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 86.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.8% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 6.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.0%CMS range 4.1–10.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.18 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 116.3 residents a day — about 97% occupied, or roughly 4 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.28 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.29 hrs/resident/day on weekends vs 3.78 on weekdays — 13% thinner on weekends. RN hours go from 0.56 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 34% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
16 citations, most serious first. The 11 most serious are shown; the remaining 5 are one tap away and print in full.
- Immediate jeopardy · J2025-03-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint # NJ 180316 Based on interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to provide adequate supervision for a cognitively impaired resident with a known history of exit-seeking behaviors which resulted in the resident eloping on 11/20/2024. The deficient practice was identified for 1 of 2 residents reviewed for elopement (Resident #12). Resident #12, who was cognitively impaired with a known history of exit-seeking, eloped from the facility on 11/20/2024. The staff reported last seeing Resident #12 in their room at 6:15 AM on 11/20/2024. The resident wore a wanderguard (a personal alarm that triggers at exits to alert staff) to their right ankle that the physician ordered to be checked for placement and function every shift, and was last checked during the night shift on 11/19/2024. On 11/20/2024 at 6:39 AM, the local police department called the facility to report that Resident #12 was found off the facility's premises at an adjacent assisted living facility. Resident #12 was returned to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-15 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, medical record review, and review of other pertinent facility documentation on 07/14/2025 and 07/15/2025 it was determined that the facility failed to develop a comprehensive person-centered care plan (CP), and failed to follow the facility Licensed Practical Nurse (LPN), Registered Nurse (RN) and Unit Manager (UM) job descriptions for 1 of 3 residents (Resident #3) reviewed for CPs.This deficient practice was evidenced by the following:According to the admission Record (AR), Resident #3 was admitted to the facility with diagnoses which included but were not limited to hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (a condition where blood flow to the brain is blocked, depriving brain cells of oxygen) affecting right dominant hand; muscle weakness; other abnormalities of gait and mobility; cognitive communication deficit; and noninfective gastroenteritis and colitis, unspecified. According to the Minimum Data Set (MDS), an assessment tool, dated 04/23/2025, Resident #3…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-24 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain a homelike environment that accommodated the resident needs and preferences. This deficient practice was identified for 1 of 23 residents reviewed (Resident# 311) and was evidenced by the following: During the initial tour of the facility on 03/18/2025 at 10:04 AM, the surveyor observed Resident #311in bed with both knees bent and the soles of both feet touching the footboard. The surveyor noted that Resident #311 filled the entire length of the bed and was not slouched towards the bottom. When asked if Resident #311 was comfortable, they stated that they have asked for the bed to be lengthened when they entered but nothing was done about it. On 03/19/2015 at 09:26 AM, the surveyor observed the resident in bed with both knees bent and the soles of both feet touching the footboard. The surveyor reviewed the medical record for Resident #311. A review of the admission Record, an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-24 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and pertinent facility documentation, it was determined that the facility failed to maintain a homelike environment that was clean, safe, and sanitary. This deficient practice was identified for 2 of 2 units (A Unit and B Unit). This deficient practice was evidenced by the following: On 03/19/2025 at 09:30 AM, Surveyor #1 observed the pantry area of A Unit. There was black debris on the floor near the refrigerator, and the microwave had brown debris inside and chipped paint. On 03/19/2025 at 10:14 AM, Surveyor #1 observed the pantry area of B Unit. A cabinet drawer near the refrigerator was missing, another drawer near the sink was off track, and a plunger along with a white rack was stored under the counter in plain sight. Additionally, the microwave contained brown debris. During an interview with Surveyor #1 on 03/21/2025 at 10:21 AM, the Registered Nurse/Unit Manager #1 (RN/UM #1) said that all facility staff are responsible for maintaining cleanliness on the units and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-24 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to establish a system of records for all controlled drugs in sufficient detail to enable an accurate reconciliation for the dispensing of controlled medications for 1 out of 3 medication carts inspected for the Medication Storage and Labeling task. This deficient practice was evidenced by the following: On 03/18/2025 at 10:31 AM, in the presence of the Licensed Practical Nurse (LPN)# 1, the surveyor inspected the medication cart on A wing labeled cart one for storage and labeling of medications. During reconciliation of controlled medications, the surveyor observed 7 Lyrica (a medication used to treat pain due to nerve damage) 75mg (milligram) in the blister pack in the narcotic box, but the Controlled Drug Sheet (CDS) documented 8 were left. The surveyor also observed 18 Oxycodone HCL Oxycontin (a narcotic medication used to treat pain)15 mg in the blister pack in the narcotic box, but the CDS documented 19 were left. Lastly the surveyor observed 37…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-24 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to a) ensure all medical supplies were stored in accordance with professional standards by having expired supplies, and b) keep medications labeled properly specifically by not labeling medications with an opened date. The deficient practice was identified in 1 of 1 medication storage rooms inspected and 2 of 3 medication carts reviewed under the Medication Task. The deficient practice was evidenced by the following: a) On [DATE] at 10:01 AM while on Unit B, the surveyor inspected the medication room. At that time 7 culture and sensitivity transfer straw kits were observed with the expiration date of 10/23. At the that time the surveyor interviewed the Unit Manger (UM). The UM said she doesn't think the center uses the kits anymore. When asked if there should be anything expired in the medication room, the UM replied, no there shouldn't be anything expired. b) On [DATE] at 10:23 AM while on Unit…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-24 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and pertinent facility documentation, it was determined that the facility failed to properly dispose of garbage and refuse. This deficient practice was identified outside on the facility's property. This deficient practice was evidenced by the following: On 03/18/2025 at 10:21 AM, the surveyor observed a garage in the facility's parking lot, where there were several items, including, but not limited to, a cart for oxygen tanks filled with empty portable tanks, a large oxygen tank, wooden pallets, a toilet, and a wheelchair. On 03/18/2025 at 10:22 AM, the surveyor observed several items near the trash can and garbage compactor outside of the facility, including, but not limited to, a folded mattress, a television, tires, crates, and chairs. On 03/18/2025 at 10:23 AM, the surveyor observed several items behind the facility, in the parking lot near a storage bin. These items included, but were not limited to, a shower bed with foam cushioning, a shower chair, trash can lids, a bed frame with a mattress, a pile of leaves, wooden flat pallets, a whirlpool…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-20 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #NJ00169106 Based on observation, interview, record review, and review of facility documentation on 11/17/23 and 11/20/23, it was determined that the facility failed to: A.) complete neurological evaluations (neuro checks) for a resident who sustained an unwitnessed fall and B.) consistently document on the Documentation Survey Report the Activities of Daily Living (ADL) status and care provided to the residents. In addition, the facility failed to follow the facility's policies titled, Activities of Daily Living, ADLs, and Falls Management. The deficient practice was identified for Residents #1 and #2, 2 of 3 residents reviewed for medical records documentation and was evidenced by the following: A.) On 11/17/23 at 11:11 AM, the surveyor observed Resident #1 near the nurse's station lying in a geriatric chair recliner (a large padded chair with a wheeled base designed to assist people with limited mobility) with their eyes closed. The resident did not respond to the surveyor's greetings. According to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-01-30 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to follow a physician's ordered pain scale when administering as needed (PRN) pain medication. This deficient practice was observed for 2 of 23 sampled resident's (Resident #76 and #73). This deficient practice was observed by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated Title 45. Chapter 11. New Jersey Board of Nursing Statutes 45:11-23.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-01-30 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 1/13/2023 from 9:11 AM to 9:47 AM, the surveyor accompanied by the Cook, observed the following in the kitchen: 1. Upon entry to the kitchen the surveyor observed a female dietary aide (DA) without a hairnet. The DA had lengthy hair that extended to the shoulder area and was in a ponytail and exposed. 2. In the dry storage room an opened box of chicken soup base was on top of a wheeled cart near the door. The box contained a plastic bag of yellow soup base that was exposed to the air. When interviewed the cook stated, It should be closed and not exposed to the air. On a middle shelf of a multi-tiered shelf, a 25-pound bag of rice was opened and exposed. On interview the cook agreed it should be sealed to prevent contamination. 3. A can of diced pears was observed on a middle rack on a wheeled can storage cart. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-30 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain a sanitary environment and ensure that equipment and furniture is clean and in good repair on 1 of 2 units, Unit A. This deficient practice was evidenced by the following: On 1/17/2023 9:47 AM, a tour of the Central Shower room located on A Wing, hallway 3 was conducted and the following was observed: A large yellow stain on the floor in the doorway of the Training Toilet room in the unit shower room. A discolored shower bed cushion containing multiple rips along the front edge. Two blue shower curtains that were hanging in the unit shower room containing multiple brown and black stains. Four rusty shower curtain rods were noted hanging up. On 1/19/2023 at 10:18 AM, on A Wing, hallway 2, two fabric chairs containing multiple stains were noted in the hall near room [ROOM NUMBER]. On 1/19/2023 at 10:37 AM, during an interview with the surveyor, the Director of Housekeeping (DOH)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 5 citations
- Potential for harm · D2023-01-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Resident #11 Based on observations, interview, and record review it was determined that the facility failed to maintain respiratory equipment in a sanitary manner. This deficient practice was observed for 1 of 2 residents (Resident #11) surveyed for respiratory care. The deficient practice was evidenced by the following: On 1/17/2023 at 9:05 AM the surveyor observed an oxygen concentrator (a machine that pulls in the air around you and filters out the nitrogen) in Resident #11's room. The oxygen tubing and nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient in need of respiratory help) was observed to be dated but the surveyor was unable to read the label. The surveyor observed a nebulizer mask on the resident's floor. The mask was not protected from contamination. According to Resident #11's admission Record, Resident #11 was admitted to the facility with the following but not limited to diagnoses: Acute on chronic congestive heart failure (a chronic condition in which the heart doesn't pump blood as it should), chronic obstructive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-30 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and review of other facility documentation it was determined that the facility failed to 1.) date medication when opened and stored for continued use as well as failed to dispose of expired medications and 2.) failed to properly store a respiratory medication according to facility policy. This deficient practice was identified for 1 of 2 medication storage rooms (A wing) and 1 of 2 residents (Resident #11) surveyed for respiratory care. This deficient practice was evidenced by the following: 1. On 1/17/2023 at 8:34 AM, the surveyor reviewed the locked Medication room on A wing with the Licensed Practical Nurse/Unit Manager (LPN/UM). In the locked Medication Refrigerator, the following was observed: 1. Influenza vaccine 5 ml (milliliter) multi dose vial in a broken box dated 12/14/22. The vial was undated, and the LPN/UM said the vial is good for 28 days after it was opened. 2. Lispro Insulin 100/ml opened and undated. It was contained in a hard plastic bottle with a lid. At 8:38 AM LPN/UM said when the vial is opened, we date it with the sticker that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-30 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to ensure personal protective equipment (PPE) (equipment such as, but not limited to gowns, gloves, and eye protection worn to protect the wearer from the spread of infection or illness) was used appropriately when entering resident rooms that were under precautions for COVID-19 (a potentially deadly respiratory virus). This deficient practice was evidenced by the following: On 1/13/2023 at 10:34 AM, during the initial tour of the facility, the surveyor observed room [ROOM NUMBER] on A Wing. room [ROOM NUMBER] was within the facility designated Yellow Zone as shown on the facility provided floorplan. Outside of the room was a bin containing gowns, gloves, and masks. There were no signs or notifications on the door or in the doorway. Inside of room [ROOM NUMBER] was a staff member, later identified as the Speech Language Therapist (SLT) sitting down adjacent to Resident #339.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-30 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to adequately monitor the use of an antibiotic by administering 13 of the prescribed 14 doses. The deficient practice was identified for 1 of 5 residents (Resident #47) reviewed for Unnecessary Medications. This deficient practice was evidenced by the following: A review of Resident #47's physician orders located in the electronic medical record revealed that he/she was prescribed Bactrim 800-160 milligrams (an antibiotic) for a bacterial infection to be given twice a day for seven days. The Bactrim administration started on January 12, 2023, at 9:00 PM. A review of Resident #47's January 2023 Medication Administration Record revealed that on January 13, no dose of Bactrim was given at 9:00 AM. On 1/20/2023 at 9:12 AM, during an interview with the surveyor, the Unit Manager/Licensed Practical Nurse (UMLPN #1) confirmed a Bactrim dose was not administered on January 13 at 9:00 AM. On interview LPN/UM#1 stated I could not tell you when asked if there was a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2021-01-29 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and review of other facility documentation, it was determined the facility failed to ensure a reconciliation of controlled substances in the Automated Medication Dispensing System (AMDS) was performed daily from 12/12/20 through 1/25/21. This deficient practice was evidenced by the following; On 1/25/21 at 10:46 AM, the surveyor reviewed the AMDS Controlled Substances Log (a book that contains declining count pages for each narcotic) with the Licensed Practical Nurse (LPN) on Unit B. There were 19 narcotics listed as being in the AMDS. Each declining count page was labeled with the medication and dosage at the top and contained multiple lines for date, time, count correct (had to check yes or no), a line for the coming on duty nurse's signature and a line for the going off duty nurse's signature. On the top line of all 19 pages was the date of 12/12/20 with Book Transfer written. When asked the LPN said the shift count sheets were in the back of the log. The surveyor looked at the back of the Controlled Substances Log and there were no signatures on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$16,153 in federal fines across 1 penalty.
- $16,153 — penalty dated 2025-03-24
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| MENDELOVITZ, LIBBI | Individual | DIRECT OWNERSHIP INTEREST | since 04/01/2022 |
| 3809 BAYSHORE RD LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | since 06/20/2023 |
| ROSENBERG, AVRAHAM | Individual | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | since 06/20/2023 |
| STERN, SAMUEL | Individual | CORPORATE OFFICER | since 04/01/2022 |
| BRUNO, KAREN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/11/2021 |
| ONWUKA, ALOYSIUS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
CMS files one row per role, so the 10 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $3.2M paid to related parties — landlords or management companies under common ownership — equal to about 25% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NJ
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Jersey Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 315508. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-24, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.