Pelican Pointe Post Acute Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Pelican Pointe Post Acute Nursing & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 24, 2025

  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. […]

• No harm, potential for more than minimal, patternF658Jan 30, 2023

  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… […]

• No harm, potential for more than minimal, patternF812Jan 30, 2023

  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. […]

• No harm, potential for more than minimal, patternF755Jan 29, 2021

  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. […]

• No harm, potential for more than minimal, isolatedF656Jul 15, 2025

  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,… […]