Cycle 1
Health 2025-03-24 · Fire 2025-03-24
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
North Cape May, NJ
Pelican Pointe Post Acute Nursing & Rehabilitation
3-star overall rating with 2-star inspections with $16,153 in total fines with 7 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
3809 Bayshore Road, North Cape May, NJ
(609) 898-0677
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
111
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2011-05-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.45
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.31
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.68
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.17
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
4.06
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,863
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
53.46
Composite VBP score used to determine payment impact.
Payment multiplier
1.0082
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 20.51% · Performance 16.56% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
2.67
Baseline 6.39% · Performance 7.04% · Measure score 2.67 · Achievement 2.67 · Improvement 0
Total nurse turnover
6.44
Baseline 50.00% · Performance 37.36% · Measure score 6.44 · Achievement 6.44 · Improvement 4.52
Adjusted total nurse staffing
2.27
Baseline 4.27 hours · Performance 3.72 hours · Measure score 2.27 · Achievement 2.27 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.58% |
10.72%
2.9 pts worse
|
No Different than the National Rate · Eligible stays 161 · Observed rate 16.77% · Lower 95% interval 9.91% |
| Discharge to community | 42.13% |
50.57%
8.4 pts worse
|
No Different than the National Rate · Eligible stays 142 · Observed rate 35.21% · Lower 95% interval 33.05% |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 99.09% |
95.27%
3.8 pts better
|
Numerator 109 · Denominator 110 |
| Falls with major injury | 0.91% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 110 |
| Discharge self-care score | 80.26% |
53.69%
26.6 pts better
|
Numerator 61 · Denominator 76 |
| Discharge mobility score | 80.26% |
50.94%
29.3 pts better
|
Numerator 61 · Denominator 76 |
| Pressure ulcers or injuries, new or worsened | 3.64% |
2.29%
1.4 pts worse
|
Numerator 4 · Denominator 110 · Adjusted rate 3.76% |
| Healthcare-associated infections requiring hospitalization | 7.04% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 113 · Observed rate 7.08% · Lower 95% interval 4.14% |
| Staff COVID-19 vaccination coverage | 100% |
8.2%
91.8 pts better
|
Numerator 219 · Denominator 219 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 78.95% |
56.45%
22.5 pts better
|
Numerator 60 · Denominator 76 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 69 · Denominator 69 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 14.93% |
25.2%
10.3 pts worse
|
Numerator 10 · Denominator 67 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
2.1
0.9 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 0.9 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
1.1
1 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.8 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
93.0%
6.5 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.9% · Q4 98.9% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.2%
2.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
2.4%
1 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.2% · Q3 3.2% · Q4 2.2% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.2% |
11.4%
9.2 pts better
|
11.4%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.2% · Q3 1.1% · Q4 4.5% · 4Q avg 2.2% |
| Percentage of long-stay residents who lose too much weight | 2.9% |
4.6%
1.7 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 0.0% · Q3 5.1% · Q4 1.4% · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.8% |
19.0%
5.8 pts worse
|
19.6%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 26.8% · Q3 23.8% · Q4 21.3% · 4Q avg 24.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.3% |
13.5%
0.8 pts worse
|
16.7%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 16.4% · Q3 9.2% · Q4 15.0% · 4Q avg 14.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 3.3% |
9.8%
6.5 pts better
|
16.3%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 2.9% · Q3 4.8% · Q4 2.4% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.2% |
9.7%
6.5 pts better
|
14.9%
11.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.5% · Q3 6.2% · Q4 1.3% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.7%
0.4 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.3% |
15.9%
7.4 pts worse
|
19.8%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 19.0% · Q3 24.1% · Q4 21.6% · 4Q avg 23.3% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
6.0%
2 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.4% · Q3 4.1% · Q4 2.6% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.4% |
78.7%
17.7 pts better
|
81.7%
14.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.7% · Q2 97.2% · Q3 94.2% · Q4 96.9% · 4Q avg 96.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.8% |
8.2%
2.4 pts better
|
12.0%
6.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.8% · Observed 5.7% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.2%
0.4 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 1.5% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.1% |
80.1%
19 pts better
|
79.7%
19.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.5% |
25.4%
7.9 pts better
|
23.9%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.5% · Observed 16.0% · Expected 21.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-30 · Fire 2023-01-30
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2021-01-29 · Fire 2021-01-29
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-24
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-04-09
F · Potential for more than minimal harm
2025-03-24
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-04-09
F · Potential for more than minimal harm
2025-03-24
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2025-04-09
F · Potential for more than minimal harm
2025-03-24
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-04-09
F · Potential for more than minimal harm
2025-03-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-09
F · Potential for more than minimal harm
2025-03-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-09
F · Potential for more than minimal harm
2025-03-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-09
F · Potential for more than minimal harm
2025-03-24
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-04-09
F · Potential for more than minimal harm
2025-03-24
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-04-09
F · Potential for more than minimal harm
2025-03-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-09
F · Potential for more than minimal harm
2025-03-24
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-04-09
E · Potential for more than minimal harm
2025-03-24
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-09
F · Potential for more than minimal harm
2023-01-30
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-03-21
F · Potential for more than minimal harm
2023-01-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-21
F · Potential for more than minimal harm
2023-01-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-01
F · Potential for more than minimal harm
2023-01-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-21
F · Potential for more than minimal harm
2023-01-30
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-03-21
F · Potential for more than minimal harm
2023-01-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-15
E · Potential for more than minimal harm
2023-01-30
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2023-03-21
E · Potential for more than minimal harm
2023-01-30
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-03-21
E · Potential for more than minimal harm
2023-01-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-21
E · Potential for more than minimal harm
2023-01-30
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-03-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-07-18
J · Immediate jeopardy
2025-03-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-24
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-24
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-24
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-24
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-24
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-04-09
D · Potential for more than minimal harm
2023-11-20
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-12-08
E · Potential for more than minimal harm
2023-01-30
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-03-02
E · Potential for more than minimal harm
2023-01-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-03-02
D · Potential for more than minimal harm
2023-01-30
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-03-08
D · Potential for more than minimal harm
2023-01-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-03-02
D · Potential for more than minimal harm
2023-01-30
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2023-03-02
D · Potential for more than minimal harm
2023-01-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-02
D · Potential for more than minimal harm
2023-01-30
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-03-02
E · Potential for more than minimal harm
2021-01-29
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2021-03-03
Penalties and ownership
What sits behind the stars
$16,153
2025-03-24
Fine
Fine · fine $16,153
Fine
Ownership
Mendelovitz, Libbi
5% Or Greater Direct Ownership Interest · Individual
3809 Bayshore Rd LLC
5% Or Greater Mortgage Interest · Organization
Bruno, Karen
Operational/Managerial Control · Individual
Onwuka, Aloysius
Operational/Managerial Control · Individual
Rosenberg, Avraham
5% Or Greater Security Interest · Individual
Stern, Samuel
Corporate Officer · Individual
Nearby options
Other facilities in reach
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North Cape Center
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4-star overall rating with 3-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Complete Care At Court House, LLC
Cape May Court House, NJ
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Crest Haven Nursing And Rehabilitation Center
Cape May Court House, NJ
4-star overall rating with 3-star inspections with $83,230 in total fines with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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