Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at North Cape Center during CMS and state inspections, most recent first.
The facility failed to serve meals on time to residents in the second-floor secure unit, with lunch consistently delivered late to dining rooms. Observations showed meal trays arriving at 12:48 PM, but not distributed until 1:05 PM, contrary to the scheduled times. Interviews revealed that the delay was due to staffing constraints, as staff were occupied with passing trays and could not assist residents with feeding simultaneously.
The facility failed to properly store nebulizer masks for two residents, did not implement Enhanced Barrier Precautions for a resident with leg wounds, and an LPN handled medication without gloves. These lapses in infection control were confirmed by staff and observed during surveys.
A facility failed to assess a resident's ability to self-care for a [NAME] tube, potentially risking a respiratory infection. The resident, with a history of heart failure and larynx neoplasm, was cognitively intact but lacked documented assessment for self-management. Staff interviews confirmed the resident managed the tube without prior interdisciplinary team approval, and the DON acknowledged the absence of a policy or assessment for such self-care.
A resident with a left ankle fracture raised grievances about medication administration, cleanliness, and food quality. The facility failed to document the resolution of these grievances, as required by their policy. The Administrator admitted to meeting with the resident but did not document these interactions, leaving the grievance form incomplete.
A resident with heart failure and a history of malignant neoplasm of the larynx was not provided with a comprehensive care plan addressing their oxygen therapy and [NAME] tube management. Despite being cognitively intact, the resident's care plan lacked documentation for these critical services. Observations and staff interviews confirmed the oversight, which was contrary to the facility's policy on person-centered care plans.
A facility failed to apply a splint device as ordered for a resident with a right hand contracture. The resident, who had a history of stroke and right-sided weakness, was observed without the splint on multiple occasions. Nursing staff documented the splint's application without verifying its placement, relying on verbal confirmation from CNAs. The DON confirmed that staff were expected to verify placement before documentation, as per facility policy.
A resident with a history of heart failure and malignant neoplasm of the larynx was administered oxygen without a physician's order. The resident was observed receiving oxygen via a trach collar, and staff confirmed the absence of an order. The facility's policy requiring verification of an order for oxygen was not followed, as confirmed by the DON and MD.
Delayed Meal Service on Second-Floor Secure Unit
Penalty
Summary
The facility failed to provide meals to residents on the second-floor secure unit in accordance with the established meal schedule. Specifically, lunch meals were consistently delivered late to the Back Dining Room (BDR) and Front Dining Room (FDR), affecting two residents among others. Observations revealed that meal trays were delivered to the unit at 12:48 PM, but food trays were not distributed until 1:05 PM, despite the meal schedule indicating that meals should be served at 12:00 PM and 12:30 PM. This delay was confirmed by interviews with residents, including one who expressed uncertainty about meal times and another who showed signs of agitation due to the delay. Interviews with the Dietary Manager (DM) and the Regional Dietary Manager (RDM) revealed awareness of the issue, with the DM acknowledging that meals were always late and attributing the delay to the need for staff assistance in feeding residents. The administrator confirmed the practice of serving the second-floor FDR last due to staffing constraints, as staff were occupied with passing trays and could not simultaneously assist residents with feeding. The facility's policy on meal distribution emphasized timely delivery, yet the observed practices did not align with this policy, leading to the deficiency.
Infection Control and EBP Failures in LTC Facility
Penalty
Summary
The facility failed to properly store nebulizer masks for two residents, R71 and R78, who were observed for breathing treatments. R71's nebulizer machine and masks were found on the bedside table without being stored in a bag, as confirmed by RN1 and the Director of Nursing (DON). Similarly, R78's nebulizer masks were not stored properly, as observed by LPN1, who acknowledged the oversight. The DON reiterated the expectation that all tubing and masks should be labeled, dated, and stored in a bag to prevent infection spread. The facility also failed to implement Enhanced Barrier Precautions (EBP) for R44, who had bilateral lower leg wounds requiring care. Despite having an order for wound care, there were no EBP postings observed in R44's room. Both the DON and the Infection Preventionist confirmed that R44 should have been on EBP since the treatment began. The lack of EBP postings was noted during observations, indicating a lapse in infection control protocols. Additionally, during a medication administration observation, LPN9 was seen handling a Gabapentin tablet with bare hands, contrary to the facility's policy requiring gloves. This was confirmed by RN2 and the DON, who stated that gloves should be worn before touching medications. The facility's policy on medication administration clearly outlines the need for handwashing and glove use prior to handling tablets, which was not followed in this instance.
Failure to Assess Resident's Ability for Self-Care of [NAME] Tube
Penalty
Summary
The facility failed to ensure that the interdisciplinary team assessed a resident's ability to self-care for a [NAME] tube, which could potentially lead to a respiratory infection. The resident, identified as R27, was readmitted to the facility with diagnoses including heart failure, aphonia, and a history of malignant neoplasm of the larynx. Despite having a Brief Interview for Mental Status (BIMS) score indicating cognitive intactness, there was no documentation of an assessment conducted by the staff to evaluate R27's capability to manage his [NAME] tube independently. Interviews with staff and the resident revealed that R27 was self-managing the [NAME] tube without prior assessment or approval from the interdisciplinary team. The Licensed Practical Nurse (LPN) confirmed that the resident cleaned the tube himself, and the Director of Nursing (DON) acknowledged the absence of a policy or assessment for self-care of the [NAME] tube. The DON confirmed that an assessment should have been completed to ensure proper techniques were used by the resident, followed by a meeting with the interdisciplinary team to discuss and agree on the resident's ability to perform the self-care.
Failure to Resolve Resident Grievance
Penalty
Summary
The facility failed to provide a resolution to a grievance raised by a resident, identified as R151, who was admitted with a left ankle fracture. The resident's grievance, documented on a form dated 06/25/24, included concerns about a nurse attempting to administer medications too soon after a previous dose, the facility being dirty with blood on a privacy curtain and shower grab bar, and feces on the floor during a shower. Additionally, the resident complained about the food being cold. The grievance form lacked documentation in the section designated for the resolution of the grievance, including whether the grievance was resolved and if the resident or their representative was notified of the resolution. During an interview, the Administrator acknowledged meeting with the resident several times but admitted to not documenting these meetings. The facility's policy requires the Administrator, serving as the Grievance Officer, to oversee the grievance process, including providing a written resolution. The policy outlines specific steps for documenting grievances, such as the date received, a summary of the grievance, steps taken to investigate, findings or conclusions, and any corrective actions. However, these steps were not followed, as evidenced by the incomplete grievance form for R151.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident, identified as R27, who was readmitted with diagnoses including heart failure, aphonia, and a personal history of malignant neoplasm of the larynx. Despite being cognitively intact with a BIMS score of 15 out of 15, R27 was receiving oxygen therapy and managing a [NAME] tube independently. However, the care plan did not include provisions for oxygen therapy or the [NAME] tube, which was a significant oversight. Observations and interviews confirmed the deficiency. On a specific date, R27 was observed receiving oxygen via a trach collar connected to a [NAME] tube, yet these were not reflected in the care plan. Both a registered nurse and the Director of Nursing acknowledged the absence of these critical elements in the care plan, confirming that the care plan should have included the services R27 was receiving. The facility's policy on person-centered care plans mandates that all services provided to a resident must be documented, which was not adhered to in this case.
Failure to Apply Splint Device as Ordered
Penalty
Summary
The facility failed to ensure that a splint device was applied according to the physician's orders for a resident with a right hand contracture. The resident, who was cognitively intact and had a history of a stroke resulting in right-sided weakness, was observed without the splint applied on multiple occasions. The resident reported not receiving exercises or having the splint applied daily, and the splint was found in a basket on the bedside table during observations. Interviews with nursing staff revealed that the splint application was documented without verification of its actual placement. Licensed Practical Nurses (LPNs) admitted to documenting the splint's application based on verbal confirmation from Certified Nurse Aides (CNAs) rather than direct observation. The Director of Nursing (DON) confirmed that the expectation was for nursing staff to follow doctor's orders and verify the placement of any durable medical equipment before documentation. The facility's policy emphasized the importance of a restorative nursing program to maintain optimal functioning, which was not adhered to in this case.
Failure to Obtain Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to obtain a physician's order prior to administering oxygen to a resident, identified as R27, who was readmitted with diagnoses including heart failure and a history of malignant neoplasm of the larynx. R27 was observed receiving oxygen via a trach collar connected to an oxygen concentrator set at five liters per minute, which was further connected to another machine to increase the concentration. During an interview, an LPN confirmed that there was no order for the oxygen administration, and the Director of Nursing later verified this lack of order. The deficiency was further confirmed during an interview with the Medical Doctor, who stated that an order should be in place for any patient receiving oxygen. The facility's policy on oxygen concentrators, which requires verification of an order, was not followed. This oversight had the potential to cause adverse reactions for R27 due to the unauthorized administration of oxygen.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near North Cape May
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pelican Pointe Post Acute Nursing & Rehabilitation | 1 mi | ★★★★★ | 0 | 0 |
| Complete Care At Court House, Llc | 9.6 mi | ★★★★★ | 1 | 0 |
| Crest Haven Nursing And Rehabilitation Center | 10.8 mi | ★★★★★ | 2 | 0 |
| Fountain Springs At Cape May Nursing & Rehab Cente | 15.4 mi | ★★★★★ | 0 | 0 |
| Excelcare At Lewes Llc | 18.5 mi | ★★★★★ | 26 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.