Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Mystic Meadows Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with cerebral palsy and depression, and intact cognition per BIMS, was observed using a motorized wheelchair that was heavily soiled with food crumbs, dust, and other debris on multiple surfaces and wheels. The resident could not recall when it was last cleaned, the care plan did not include a focus for the motorized wheelchair, and facility records showed the chair had last been cleaned in October, despite staff stating wheelchairs were cleaned monthly or as needed.
An LPN administered medications to a resident and then left the medication cart unattended in the hallway with the computer screen open and displaying the resident’s PHI, including name, photo, DOB, physician, allergies, code status, orders, vital signs, and medical condition. The surveyor observed that the screen faced the hallway, and the LPN stated it should have been locked while unattended; the DON also stated nurses should lock the screen to protect resident privacy.
Homelike Environment Not Maintained on Unit: A surveyor observed multiple areas of disrepair and poor upkeep on one unit, including debris on a bedroom wall, torn cloth behind a bed, unfinished spackling and holes in a bathroom wall, and a shower room door with flaking metal and peeling paint. The surveyor also found an open, tilted sharps container filled with razors. The LNHA said a homelike environment was important for resident dignity and comfort, while the MD stated he was unaware of the issues and acknowledged the sharps container should have been emptied.
A resident with dementia and severe cognitive impairment was observed with a tab alarm clipped to the shirt while seated in a geriatric chair. Records showed no physician order, restraint assessment, or care plan interventions for the alarm, and the MDS did not indicate alarm use. Staff confirmed the resident had been wearing the alarm routinely, but documentation for its use was missing and the RN/MDS Coordinator stated it should have been coded as a restraint.
A resident with SIRS, protein-calorie malnutrition, heart failure, and cognitive deficits was ordered to wear derma-sleeves, Geri-sleeves, and fingerless gloves for skin protection. Surveyors repeatedly observed the resident without the ordered items, while the TAR documented them as applied every shift. Staff confirmed the resident should wear the protectors at all times except during care, noted the resident sometimes removed them, and there was no documentation supporting the removals.
Failure to provide ordered splinting for a resident with right-sided hemiplegia and a right hand contracture. The resident was observed with the right arm flexed and held close to the body, and no splint or hand roll was in use or present in the room during multiple observations. Although the care plan and OT eval called for a resting hand splint, there was no active MD order for the right upper extremity at the time, and a later unconfirmed order was created by the DOR and backdated after the surveyor’s inquiry.
Failure to Document Required Reweight After Significant Weekly Weight Loss: A resident with CHF, dementia, cachexia, and other conditions was on a therapeutic diet, supplement, and weekly weight monitoring. The resident had a 6.8-lb weight loss in one week, which met the facility’s reweight threshold, but no documented reweight was found. Staff interviews confirmed that the weight change should have been reweighed and documented, and the DON acknowledged the missing documentation.
Respiratory care was not provided safely and as ordered for two residents. One resident with COPD and HF had oxygen tubing running through a trash bin, an unlabeled line, no oxygen signage, and an unbagged neb mask left exposed on the bedside table; the DON stated the mask should be bagged and the tubing should not touch the trash bin. Another resident with orders for O2 tubing storage had no tubing in the room during repeated observations, yet the TAR was signed off as completed; the RN/UM, LPN, and DON all confirmed the tubing should have been present and stored in the room as ordered.
An LPN administered medications to a resident and then returned to the hallway medication cart to place an ophthalmic suspension bottle in the top drawer, but left the cart unlocked while going into the resident's room and out of view of the cart. The LPN stated the cart should be locked at all times, and the DON later confirmed that medication carts should be locked at all times. The facility policy required drugs and biologicals to be stored in locked compartments and medications to remain under direct observation or locked during a med pass.
Improper hand hygiene was observed in the [NAME] Unit dining room when a CNA assisted two residents with hand hygiene before lunch using folded wet napkins that did not contain alcohol, and did not perform hand hygiene on herself between assisting the residents. The CNA stated she used the same wet napkins for residents and herself, while the LNHA and IP stated that hand hygiene should be done with soap and water or alcohol-based hand sanitizer, including between resident contacts.
The facility failed to maintain proper food safety and sanitation practices, including inaccurate temperature logs, insufficient sanitizer levels, and unclean equipment. Additionally, nourishment rooms and refrigerators were not maintained at appropriate temperatures, and staff hygiene practices were inadequate.
A facility failed to provide the required SNF ABN and NOMNC to a resident discharged from Medicare Part A services. Despite the resident remaining in the facility, the necessary notices were not issued, as the resident did not want to participate in therapy. The facility's policy mandates these notices when Medicare services end, but they were not provided in this instance.
A facility failed to accurately document medical records for a resident, leading to a deficiency. The resident, with diagnoses including cramp, spasm, and chronic pain, had an indwelling urinary catheter and scheduled medications. The TAR and MAR showed multiple unsigned physician orders for catheter flushes and medication administration. Interviews with staff revealed inconsistencies in documentation, with the Interim LNHA admitting to performing catheter flushes without proper documentation. The primary MD emphasized the importance of following orders to prevent complications. The facility's policy required documentation, but the MAR and TAR contained blanks, resulting in a deficiency.
An LPN failed to perform proper hand hygiene during medication administration, as observed by a surveyor. The LPN did not wash hands after removing gloves following blood pressure measurement and medication administration for a resident. Interviews with the LPN/Unit Manager and LPN/Infection Preventionist confirmed the requirement for hand hygiene before and after glove use, as per the facility's policy.
Soiled Motorized Wheelchair Not Maintained in Dignified Condition
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not maintaining the cleanliness and dignified appearance of the resident’s motorized wheelchair. During an initial tour, the surveyor observed the wheelchair heavily soiled with fresh and dried food crumbs, dust, and other unidentified debris on the bilateral front and rear wheels, all wheel fenders, bilateral seat side rails, footrest, seat board, controller, power base, and leg rest hangers. The resident was unable to recall when the chair was last cleaned. Resident #80 was admitted with diagnoses including cerebral palsy and depression. The most recent MDS dated 11/15/2025 showed a BIMS score of 14 out of 15, indicating intact cognition, and also documented impairments in both upper and lower extremities and the need for clean-up assistance. The resident’s comprehensive care plan did not include a focus for use of the motorized wheelchair. The DON stated wheelchairs were maintained by housekeeping on a monthly or as-needed basis, and the housekeeping director stated all wheelchairs were scheduled monthly or as needed; however, the resident’s wheelchair was last cleaned in October 2025, and the November and December 2025 schedule only showed a cross mark for the resident’s unit without naming specific residents.
Resident Health Information Left Visible on Unattended Medication Cart
Penalty
Summary
The facility failed to respect a resident’s right to confidentiality of personal and medical records by leaving private health information exposed on an open, unattended computer screen in an area accessible to the public. During medication administration observation on 12/5/2025, an LPN administered metformin 500 mg and prednisolone acetate ophthalmic suspension to Resident #21, then returned to the medication cart in the hallway to place the eye drop bottle in the top drawer. The surveyor observed the computer screen on the cart left open and displaying the resident’s photograph, name, location, gender, date of birth, age, physician, allergies, code status, physician orders, current vital signs including weight, and medical condition while the cart was unattended and facing the hallway. At the time of the observation, there were no residents or staff in the hallway. The surveyor asked the LPN whether the screen should be left exposed while the cart was unattended, and the LPN stated it should be on locked mode at all times and not showing resident information. During an interview on 12/9/2025, the DON stated that during medication administration, nurses should press the computer screen lock button to protect residents’ private information from being viewed by others when they leave the cart. The facility policy titled Medication Administration, revised November 11, 2024, included a guideline to provide privacy.
Homelike Environment Not Maintained on Unit
Penalty
Summary
The facility failed to maintain a homelike environment that was clean, safe, and sanitary for 1 of 4 units, the [NAME] Unit. On observation in bedroom [ROOM NUMBER], multiple black debris were scattered across the A-side wall, the cloth material behind the bed was torn in several places, and the bathroom heater vent had unfinished spackling around it with five holes noted on the bathroom wall, all with incomplete spackling. In the shower room on the same unit, the entrance door had brown, flaking metal with crumbling edges and peeling paint, and the molding adjacent to the entrance door had missing and bulging paint exposing open wall spaces. The surveyor also observed a sharp container tilted and hanging in the shower room, filled to the top with multiple blue razors and left open with its contents exposed. During interview, the LNHA stated that maintaining a homelike environment was important for residents' dignity and comfort and that environmental issues were addressed promptly by maintenance based on severity. The MD stated he completed rounds three times daily and addressed issues promptly, but he was unaware of the issues in the bedroom and shower room and acknowledged that the sharps containers should have been emptied for safety reasons. The facility policy titled Homelike Environment stated that residents are provided with a safe, clean, comfortable, and homelike environment.
Unordered Tab Alarm Used Without Required Documentation
Penalty
Summary
The facility failed to ensure that a resident was free from the use of a physical restraint when the resident was observed seated in a geriatric chair with a yellow tab alarm clipped to the resident’s shirt. The resident had diagnoses including dementia and a Quarterly MDS dated 09/19/25 showed a BIMS score of 0 out of 15, indicating severe cognitive impairment. The MDS Section P: Restraints and Alarms indicated the resident did not use any alarms, and the comprehensive care plan did not include a focus area or interventions for personal alarms. Record review showed there were no physician orders in the MAR/TAR for a personal alarm, and the EMR contained no restraint assessment or other assessment related to the use of the alarm. Staff interviews confirmed the alarm had been used routinely: an LPN stated the resident had always worn a tab alarm and that there was no physician order, while the LPN/UM stated the resident had always had a chair alarm and acknowledged that physician order, care plan, consent, and MDS documentation should have been in the chart. The RN/MDS Coordinator stated the tab alarm should have been coded as a restraint and that it was not coded because there was no physician order. The DON stated the facility did not use physical restraints, but also stated personal tab alarms were used for safety after physician consultation and that proper documentation should have been included in the care plan, nurse notes, and MDS.
Failure to Follow Orders for Skin Protectors
Penalty
Summary
The facility failed to meet professional standards of nursing practice by not following physician orders for Resident #56’s prescribed skin protectors. The resident was admitted with diagnoses including SIRS, protein-calorie malnutrition, and heart failure, and the quarterly MDS indicated short-term and long-term memory problems. The care plan identified the resident as at risk for bruising, bleeding, and skin tears related to aspirin therapy and age-related skin changes, with interventions to apply derma-legs, derma-sleeves, Geri-sleeves, and fingerless gloves at specified times for skin protection. During multiple observations, the resident was seen without the prescribed derma-legs, paperless gloves, and Geri-sleeves. The physician order summary listed orders for derma-sleeves, Geri-sleeves, and fingerless gloves every shift, and the TAR documented the skin protectors as applied every shift, but the surveyor repeatedly observed the resident not wearing them. Staff interviews confirmed the resident should have been wearing the items at all times except during care, and the LPN stated the resident sometimes removed them. The surveyor found no documentation verifying removal of the skin protectors, and the RN/UM and DON both stated that removed items should be reapplied and documented in progress notes.
Failure to Provide Ordered Splinting for Resident with Right-Sided Contracture
Penalty
Summary
The facility failed to ensure that a resident with right-sided hemiplegia and a history of TIA/CVA received the recommended services to maintain range of motion for the right upper extremity. The resident’s comprehensive care plan, revised on 10/28/2025, included an intervention to wear a right resting hand splint for 4 hours during the daytime after morning care, and an OT evaluation dated 10/24/2025 recommended a resting hand splint as tolerated and removal for hygiene for the right hand contracture. However, the active physician orders on 12/4/2025 did not include any order addressing the resident’s right upper extremity mobility, and the prior order for a right hand anti-spasticity hand roll splint had been discontinued on 2/15/2025. During observations on 12/4/2025 and 12/8/2025, the resident was seen ambulating in the hallway using the left hand to move the wheelchair, with the right leg on an immobilizer boot and the right arm bent at the elbow and held close to the body; the right hand was flexed and held by the left hand. The resident was not wearing a splint or hand roll on the right arm or hand, and none was seen in the room. On 12/9/2025, the resident pointed to a blue hand splint on the dresser and stated it had been given that day. After the surveyor asked about orthotics, an unconfirmed physician order for a right resting hand splint was created by the DOR on 12/9/2025 and backdated to 10/24/2025. The DON stated the DOR issued assistive device orders, and the DOR stated orthotic orders were issued through the electronic record and would need physician confirmation and approval.
Failure to Document Required Reweight After Significant Weekly Weight Loss
Penalty
Summary
The facility failed to follow its weight-monitoring policy for a resident with multiple nutritional and medical risk factors, including CHF, sepsis, breast cancer, dementia, anxiety, edema, and cachexia. The resident was admitted on a No Added Salt, chopped-texture diet with a daily nutrition supplement and had orders for weekly weights after weight loss. The resident also had documented difficulty or pain with swallowing, required supervision or touching assistance with eating, and was receiving a daily diuretic and opioid medication. The resident’s weight record showed 133.0 pounds on 11/7/2025, 126.2 pounds on 11/14/2025, 129.0 pounds on 11/21/2025, 128.0 pounds on 11/28/2025, and 122.2 pounds on 12/2/2025. The 6.8-pound decrease from 11/7/2025 to 11/14/2025 met the facility’s threshold for a reweight, but no documented reweight was found. During observation on 12/05/2025, the resident was in bed, appeared slightly agitated, had an untouched breakfast tray, stated he/she was in pain and had no appetite, and staff later assisted with setting up the meal. Interviews with the CNA, UM/RN, RD, and DON confirmed that staff were responsible for obtaining and documenting weekly weights and that a weight loss of more than 3 pounds in one week required a reweight and documentation. The UM/RN stated the reweight had been done but not documented, the RD stated the weight change should have been reweighted and documented, and the DON agreed that the reweight was not documented when the 6.8-pound discrepancy occurred.
Respiratory tubing and oxygen orders not followed
Penalty
Summary
Safe and appropriate respiratory care was not provided for two residents. For one resident with COPD and heart failure, the surveyor observed oxygen tubing running from an oxygen concentrator to a nasal cannula while the middle portion of the tubing was inside a trash bin and touching trash. The tubing was unlabeled, there was no oxygen signage inside or outside the room, and an unbagged nebulizer mask was later observed lying sideways on the bedside table and exposed to air. The resident’s record showed orders for ipratropium-albuterol nebulization and oxygen as needed via nasal cannula at 2 liters per minute for shortness of breath, and the DON stated that the nebulizer mask should be stored in a plastic bag when not in use and that oxygen tubing should not touch the trash bin. For a second resident with diagnoses including SIRS, protein-calorie malnutrition, and heart failure, the surveyor observed the resident in a wheelchair in the room with no oxygen tubing present. The resident’s care plan included oxygen therapy as needed for shortness of breath, and the physician order summary included orders for oxygen tubing storage to keep tubing in a bag when not in use and to change and date the respiratory bag on a schedule tied to low oxygen levels. Although the TAR documented the oxygen tubing tasks as completed every shift, the surveyor did not observe any oxygen tubing in the room during multiple observations. The RN/UM confirmed that the resident had an active order for oxygen tubing but did not have the tubing in the room, and stated the task should not have been signed off because the tubing was not present. An LPN stated the resident should have oxygen tubing stored in a bag in the room, and the DON agreed that the tubing should have been stored in the room as ordered and that staff should not have documented completion of the task when the tubing was not there. The DON also stated it was especially important for the hospice resident to have oxygen tubing readily accessible in the event of an emergency.
Unlocked Medication Cart During Administration
Penalty
Summary
The facility failed to store medications securely inside the medication cart by leaving it unlocked while unattended. During a medication administration observation on 12/5/2025 at 7:54 AM in the long-term care unit, an LPN administered metformin 500 mg and prednisolone acetate ophthalmic suspension to Resident #21. After placing the ophthalmic suspension bottle in the top drawer of the medication cart in the hallway, the LPN pushed the drawer closed but did not lock the cart, then went into the resident's room to speak with the resident with their back facing the doorway. The medication cart was not in the LPN's line of vision and remained open to the hallway. When the surveyor asked whether the medication cart was supposed to be left unattended and unlocked in the hallway, the LPN stated that it should be locked at all times. On 12/9/2025, the DON also stated that medication carts should be locked at all times. The facility's Medication Storage policy, revised 5/30/2023, stated that all drugs and biologicals will be stored in locked compartments and that during a medication pass, medications must be under the direct observation of the person administering them or locked in the medication storage area/cart.
Improper Hand Hygiene During Mealtime
Penalty
Summary
The facility failed to ensure a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections during mealtime hand hygiene in the [NAME] Unit dining room. During lunch observation, a CNA assisted two residents with hand hygiene before the meal by using a folded wet napkin for each resident, and the CNA did not perform hand hygiene on herself between assisting the two residents. During interview, the CNA stated that she used folded wet napkins, which did not contain alcohol, for resident hand hygiene during mealtimes and also used the same folded wet napkins for her own hand hygiene. The LNHA stated that hand hygiene should be performed with soap and water when hands are visibly soiled and with alcohol-based hand sanitizer when appropriate, including between resident contacts. The IP stated that the folded wet napkins used by the CNA did not contain alcohol, that hand hygiene wipes should contain at least 70% alcohol, and that the CNA should not have used the folded wet napkins for resident hand hygiene or between residents.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to handle potentially hazardous food and maintain kitchen sanitation, as evidenced by several observations. The dish machine's wash cycle gauge was broken, and the temperature was recorded manually. However, the temperature logs were pre-filled for lunch service before it occurred, indicating inaccurate record-keeping. Additionally, the sanitizer level in the three-compartment sink was insufficient, and the test strip procedure was not followed correctly, leading to potential sanitation issues. In the food preparation area, several pieces of equipment were not properly cleaned or maintained. A meat slicer had debris on its base, a mixer was left uncovered, and a can opener had a dried brown substance on its blade. Furthermore, a container of vanilla frosting was not labeled with an opening or use-by date, and leftover meatloaf in the refrigerator was not fully covered. The juice machine gun was also found with a brown substance, indicating inadequate cleaning practices. The facility's nourishment rooms and refrigerators were not maintained at appropriate temperatures, with expired and unlabeled food items present. A refrigerator was found at 70 F, holding potentially hazardous foods, and a microwave was heavily soiled. Staff hygiene practices were also lacking, with improper use of hair restraints and handwashing procedures. Logs for dishwashing and sanitation were filled in prematurely, compromising the accuracy of temperature and sanitizer levels.
Failure to Issue Required Beneficiary Notices
Penalty
Summary
The facility failed to issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) for a resident who was reviewed for Beneficiary Protection Notification. The resident began receiving Medicare Part A services and was later discharged from these services. However, the facility did not provide the necessary beneficiary notices when the resident was discharged from Medicare Part A services, despite the resident remaining in the facility. The Regional Director of Case Management acknowledged that the resident should have received these notices, but they were not issued because the resident did not want to participate in therapy. Interviews with the Director of Social Services and the Director of Rehabilitation revealed that the facility's process involves reviewing residents on Medicare Part A services during weekly Utilization Review meetings. The Social Worker is responsible for issuing the NOMNC and setting the discharge date. However, in this case, the resident's progress notes did not indicate that the resident initiated a discharge from Medicare Part A services, nor were the SNF ABN or NOMNC notices provided. The facility's policy requires these notices to be issued when Medicare-covered services are ending, regardless of whether the resident is leaving or remaining in the facility.
Deficiency in Documentation of Medical Records
Penalty
Summary
The facility failed to accurately document medical records for a resident, identified as Resident #248, which led to a deficiency. The resident had diagnoses including cramp and spasm, urinary tract infection, and chronic pain, and was noted to have an intact cognition with a BIMS score of 15 out of 15. The resident's care plan included the use of an indwelling urinary catheter and scheduled pain medications. However, the Treatment Administration Record (TAR) and Medication Administration Record (MAR) showed multiple instances where the physician's orders were not signed as completed, indicating a lack of documentation for catheter flushes and medication administration. Interviews with facility staff, including a CNA, LPN, LPN/UM, DON, and the Interim LNHA, revealed inconsistencies in the documentation process. The CNA was unsure if nurses were required to flush the catheter, while the LPN and LPN/UM acknowledged the importance of following physician orders and documenting catheter flushes in the TAR. The DON and Interim LNHA also recognized the significance of documentation, with the Interim LNHA admitting to performing catheter flushes without signing off on the TAR or writing progress notes, attributing the oversight to being busy during the holidays. The primary MD for the resident confirmed the necessity of flushing the catheter due to the resident's history of blood in it, emphasizing the importance of following the physician's order to prevent complications. Despite the facility's policy requiring documentation of medication administration and treatments, the MAR and TAR contained blanks, indicating that the required actions were not documented. The facility's failure to ensure proper documentation of medical records for Resident #248 resulted in a deficiency, as acknowledged by the DON and Interim LNHA.
Failure to Perform Proper Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to practice proper hand hygiene during medication administration, as observed by a surveyor. On the morning of June 27, 2024, an LPN was seen taking the blood pressure of an unsampled resident, cleaning the blood pressure cuff with a disinfectant wipe, and then proceeding to the medication cart without performing hand hygiene after removing gloves. Later, the same LPN donned gloves to administer medication to the resident and removed the gloves afterward, again failing to perform hand hygiene. Interviews with the LPN/Unit Manager and the LPN/Infection Preventionist confirmed that hand hygiene should be performed before and after donning and doffing gloves, as well as after cleaning equipment. The facility's hand hygiene policy, reviewed and revised in June 2023, also states that hand hygiene should be performed when indicated, using proper technique, and that the use of gloves does not replace hand hygiene. The policy specifies that hand hygiene should be performed prior to donning gloves and immediately after removing them.
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What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Little Egg Harbor Tw
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seacrest Rehabilitation And Healthcare Center | 3.4 mi | ★★★★★ | 21 | 0 |
| Manahawkin Health And Rehabilitation Center | 7.2 mi | ★★★★★ | 13 | 3 |
| Southern Ocean Center | 7.2 mi | ★★★★★ | 13 | 0 |
| Barnegat Rehabilitation And Nursing Center | 11 mi | ★★★★★ | 3 | 0 |
| Atlas Healthcare At Seashore Gardens | 14.2 mi | ★★★★★ | 0 | 0 |
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