Pelican Pointe Post Acute Nursing & Rehabilitation

Inspectors wroteBased 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; [...]

Inspectors wroteComplaint # 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: [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteComplaint #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: [...]

Inspectors wroteBased 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; [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteResident #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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]