Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
PELICAN POINTE POST ACUTE NURSING & REHABILITATION
NORTH CAPE MAY, NJ · 120 certified beds · Last Life Safety survey March 24, 2025
CMS Certification Number 315508 · first certified May 2011
Ownership
Independently operated (no chain recorded by CMS) · For profit - Limited Liability company
- Ownership changed April 1, 2022 (change of ownership)to PELICAN POINTE POST - ACUTE NURSING AND REHABILITATION from 3809 BAYSHORE ROAD OPERATIONS LLC
Position within NJ
23 citations — more than 84% of the 348 certified nursing homes in NJ. Compared within NJ rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 13 citations; the earlier surveys in the window averaged 5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: July 2026 to December 2026. This facility’s last Life Safety survey was March 2025. Facilities in NJ are typically surveyed 16–20 months after the last one (median 17), measured over 431 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
2 of the 23 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 23 Life Safety citations above. The Physical Environment Index
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in NJ, and nationally. Surveyors differ markedly between states, so the NJ figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 23 |
| Median facility in NJ | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| January 29, 2021 | 0 |
| January 30, 2023 | 10 |
| March 24, 2025 | 13 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2025-03-24 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2025-03-24 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2025-03-24 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-03-24 |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | 2 | 2025-03-24 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1 | 2025-03-24 |
| E-0041 | Implement emergency and standby power systems. | 1 | 2023-01-30 |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | 1 | 2023-01-30 |
What the citations cover
- Smoke Deficiencies 10
- Gas, Vacuum, and Electrical Systems Deficiencies 6
- Egress Deficiencies 4
- Emergency Preparedness Deficiencies 2
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 10 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 6 |
| Egress Deficiencies | 4 |
| Emergency Preparedness Deficiencies | 2 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
March 24, 2025 — 13 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (April 9, 2025) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (April 9, 2025) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (April 9, 2025) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (April 9, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (April 9, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (April 9, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 9, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (April 9, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (April 9, 2025) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (April 9, 2025) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (April 9, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (April 9, 2025) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (April 9, 2025) |
January 30, 2023 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (March 21, 2023) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (March 21, 2023) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (March 21, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (March 21, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 1, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (March 21, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (March 21, 2023) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (March 2, 2023) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Deficient, Provider has date of correction (March 21, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (February 15, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.