Mystic Meadows Rehabilitation And Nursing Center
151 Ninth Avenue, Little Egg Harbor Tw, NJ 08087 · For profit - Limited Liability company · 130 certified beds · (609) 294-3200 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 2.4% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.8% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 17.6% | 12.1% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.6% | 2.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 2.7% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 31.2% | 18.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 95.8% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.2% | 5.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 31.3% | 15.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 22.5% | 12.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.7% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 82.1% | 80.1% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 29.5% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 10.8% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.95 | 2.07 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.87 | 1.11 | 1.80 | typical |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
49.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 117 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 70.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 78 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.44 therapist hours per resident per day in 2026Q1 — more than 74% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 49.3%CMS range 42.5–58.3 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.7%CMS range 6.8–13.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 70.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 70.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 51.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.2% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.6%CMS range 4.7–12.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.34 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 130 beds and averages 86.1 residents a day — about 66% occupied, or roughly 44 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.98 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.12 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.62 hrs/resident/day on weekends vs 4.13 on weekdays — 12% thinner on weekends. RN hours go from 0.64 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
16 citations, most serious first. The 10 most serious are shown; the remaining 6 are one tap away and print in full.
- Potential for harm · D2025-12-10 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, review of medical records and other pertinent facility documents, it was determined that the facility failed to treat each resident with respect and dignity in an environment that promotes maintenance or enhancement of their quality of life by maintaining cleanliness and dignified appearance of the resident's motorized wheelchair. This deficient practice was identified in one of one resident (Resident #80) reviewed for dignity and was evidenced by the following:On 12/4/2025 at 10:57 AM, during the initial tour of the facility, the surveyor observed Resident #80 ambulating in the hallway on a motorized wheelchair. The surveyor observed the motorized chair to be heavily soiled with fresh and dried food crumbs, dusts, 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.The surveyor reviewed the medical record for Resident #80.A review of the admission Record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-10 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, review of medical record and other pertinent facility documents, it was determined that the facility failed to respect the resident's right to confidentiality of personal and medical records from unauthorized disclosure without the resident's consent by leaving the resident's private health information exposed on an open and unattended computer screen in an area accessible to the public. This deficient practice was identified for one of four unsampled residents (Resident #21) during medication administration observation.The deficient practice was evidenced by the following:On 12/5/2025 at 7:54 AM, during the medication administration observation in the long-term care unit, the surveyor observed Licensed Practical Nurse (LPN) #1 administer medications to Resident #21. After administering 1 tablet of metformin 500 milligrams and applied prednisolone acetate ophthalmic suspension to both eyes of the resident, LPN #1 returned to the medication cart located in the hallway, to place the ophthalmic suspension bottle inside the top drawer. The surveyor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-10 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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 1 of 4 units ([NAME] Unit).This deficient practice was evidenced by the following: On 12/08/2025 at 10:00 AM, in bedroom [ROOM NUMBER] on the [NAME] Unit, the surveyor observed multiple black debris scattered across the A-side wall. On the B-side, the cloth material behind the bed was torn in several places. In the bathroom, the heater vent had unfinished spackling around it, and five holes were noted on the bathroom wall, all with incomplete spackling. On 12/08/25 at 10:00 AM, in the shower room on the [NAME] Unit, the surveyor observed that the entrance door had brown, flaking metal with crumbling edges, and paint was peeling away. Molding on the wall adjacent to the entrance door showed missing and bulging paint, exposing open wall spaces. Additionally, a sharp container was tilted and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-10 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and pertinent facility documentation, it was determined that the facility failed to ensure that the resident was free from physical restraint for the purpose of discipline or convenience and not required to treat the resident's medical symptoms. This deficiency was identified for 1 of 1 resident reviewed for physical restraints (Resident #9).This deficient practice was evidenced by the following: On 12/08/25 at 10:02 AM, the surveyor observed Resident #9 on the [NAME] unit in the day room, seated in a geriatric chair (a wheelchair designed for older adults, providing comfort, safety, and support for limited mobility), watching television with peers. A yellow tab alarm device (a personal alert device used in healthcare that triggers an alarm when a resident attempts to get up from a bed, chair, or wheelchair) was clipped to Resident #9 shirt. According to the admission record, Resident #9 was admitted to the facility with diagnoses including, but not limited to,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-10 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of facility policies, it was determined that the facility failed to meet professional standards of nursing practice with respect to following physician's orders. This deficient practice was identified for one (1) of thirty-four (34) residents reviewed, Resident #56. This deficient practice was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing a medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. On 12/4/2025 at 10:56 AM, the surveyor observed Resident #56 sitting in their wheelchair (W/C) outside of the day room. The Resident was not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-10 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, review of the medical record, and other facility documents, it was determined that the facility failed to ensure that a resident who was identified as having a contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity or rigidity of joints) received recommended services to prevent further decreased in range of motion (ROM). This deficient practice was identified for 1 of 1 resident reviewed for positioning and mobility, (Resident #4) and was evidenced by the following:On 12/4/2025 at 9:45 AM, during the initial tour of the facility, the surveyor observed Resident #4 in bed while being rendered morning care.On 12/4/2025 at 10:34 AM, the surveyor observed Resident #4 ambulating in the hallway using their left hand to move the wheelchair. The resident's right leg was up on the leg rest on immobilizer boot. The resident's right arm was bent on the elbow and kept close to the body. The resident's right hand was flexed and being held by the left hand. The resident did not wear a splint or hand…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-10 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to follow facility policy and procedure for weekly weights for 1of 2 residents (Resident #1) on 1 of 3 units (Comfort Care). This deficient practice was evidenced by the following: On 12/05/2025 at 7:59 AM Resident#1 was observed in bed. Resident #1 was slightly agitated and did not prefer to communicate with the surveyor. The breakfast tray was observed on the over the bed table. The tray was observed to be untouched. Resident 31 stated that he/she was in pain and had no appetite. Resident #1 would not tell the surveyor how long their appetite had been poor, then stated, yesterday. Staff were observed to attend to Resident#1 after the surveyor had left the room. Staff were observed by the surveyor to provide assist with setting resident up to eat and opening cold cereal and pouring milk.A review of Resident #1's admission Record revealed that Resident #1 was admitted to the facility with the following but not limited to diagnoses: Congestive heart failure (a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of facility documents, it was determined that the facility failed to a.) ensure respiratory tubing was maintained in sanitary condition while being used by the resident and a nebulizer (a machine used to administer medication in the form of a mist inhaled into the lungs) mask was stored in protective covering to prevent the spread of infection and b.) follow physician orders and provide oxygen (O2) tubing to accommodate the respiratory needs of a resident ordered O2 in accordance with professional standards of practice. This deficient practice was identified for two of three residents (Resident #83 and Resident #56) reviewed for respiratory care.This deficient practice was evidenced by the following: 1.) On 12/4/2025 at 11:02 AM, during the initial tour of the facility, Surveyor #1 observed Resident #83 from the hallway, sleeping in bed connected to an oxygen concentrator running at 2 lpm (liters per minute) via a nasal cannula (NC) (a tube used to deliver oxygen though the nostrils). The surveyor observed the middle part of the oxygen…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-10 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to store medications securely inside the medication cart by keeping it locked while unattended. The deficient practice was identified for 1 of 4 unsampled residents (Resident #21) observed during medication administration. The deficient practice was evidenced by the following:On 12/5/2025 at 7:54 AM, during the medication administration observation in the long-term care unit, the surveyor observed Licensed Practical Nurse (LPN) #1 administer medications to Resident #21. After administering 1 tablet of metformin 500 milligrams and applied prednisolone acetate ophthalmic suspension to both eyes of the resident, LPN #1 returned to the medication cart located in the hallway, to place the ophthalmic suspension bottle inside the top drawer. The surveyor observed LPN #1 push the drawer close but did not lock the medication cart. LPN #1 went inside the resident's room to speak to the resident with their back facing the doorway. The medication cart was not on LPN #1's line…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-10 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and review of pertinent facility documentation, it was determined that the facility failed to ensure a safe, and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to provide residents with appropriate products for hand hygiene during mealtime, and staff did not follow hand hygiene practices consistent with accepted standards of practice. This deficiency was identified in 1 of 4 dining room observations ([NAME] Unit dining room).This deficient practice was evidenced by the following: On 12/08/25 at 11:10 AM, the surveyor observed dining for lunch on the [NAME] Unit dining room. The Certified Nurse Assistant (CNA) assisted two residents with hand hygiene before lunch using a folded wet napkin for each resident. However, the CNA did not perform hand hygiene herself between assisting each resident. During an interview with the surveyor on 12/08/25 at 11:14 AM, the CNA stated that during…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 6 citations
- Potential for harm · F2024-07-03 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to handle potentially hazardous food and maintain kitchen sanitation in a safe and consistent manner in order to prevent food borne illness. This deficient practice was evidenced by the following: On 06/26/24 from 09:29 AM until 10:17 AM, the surveyor observed the following in the presence of the Food Service Director (FSD): 1.) The surveyor requested to view the dish machine that was in service at that time. The FSD stated that the wash cycle gauge was broken, and the temperature was obtained manually. The FSD then placed a manual thermometer in the water in the base of the dish machine after the wash cycle to demonstrate the wash cycle temperature which was 178 degrees Fahrenheit (F) (manufacturers instructions that were posted on the front of the dish machine indicated expected parameters for the wash cycle temperature was 160 F and the rinse cycle temperature was 180 F). The rinse cycle…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-03 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, it was determined that the facility failed to issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) for 1 of 3 residents (Resident #56) reviewed for Beneficiary Protection Notification. The deficient practice was evidenced by the following: On 07/01/24 at 9:25 AM, the Regional Director of Case Management (RDCM) provided the SNF Beneficiary Protection Notification Review form for Resident #56, which indicated the resident started on Medicare Part A Services on 11/13/23 and was discharged from Medicare Part A Services on 12/26/23. The form further indicated the resident did not receive the SNF ABN or NOMNC beneficiary notices because he/she did not want to participate in therapy. The RDCM stated that the resident should have received the SNF ABN and NOMNC when the resident was discharged from Medicare Part A Services and remained in the facility. On 07/01/24 at 10:45 AM, the Director of Social Services (DSS) stated that residents on Medicare Part A Services were reviewed at the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-03 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint #: NJ169593 Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to accurately document in the medical records. This deficient practice was identified for 1 of 23 resident (Resident #248) medical records reviewed and was evidenced by the following: The surveyor reviewed the medical record for Resident #248. A review of the admission Record face sheet reflected that the resident had diagnoses that included, but were not limited to, cramp and spasm, urinary tract infection, and chronic pain. A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 12/30/224, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had an intact cognition. Further review of the MDS included in Section H: Bladder and Bowel, that the resident had an indwelling catheter (urinary catheter) and in Section J: Health Conditions, under pain management, that the resident received scheduled pain medications. A review of the Order Summary Report (OSR)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-03 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of facility documents it was determined that the facility failed to practice proper hand hygiene for 1 of 2 nurses observed during medication administration. The deficient practice was evidenced by the following: On 6/27/24 at 8:36 AM, the surveyor observed Licensed Practical Nurse (LPN #2) take the Blood Pressure (BP) of an unsampled resident. LPN #2 then cleaned the BP cuff with a disinfectant wipe, removed his gloves, and proceeded to the medication cart to prepare the unsampled resident's medication. At that time, LPN #2 did not perform hand hygiene. On 6/27/24 at 9:08 AM, LPN #2 donned (put on) gloves, administered the unsampled resident's medication and then doffed (removed) his gloves. At that time, LPN #2 did not perform hand hygiene. On 06/27/24 at 09:39 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) who stated that hand hygiene should be performed when donning and doffing gloves. When asked, when should hand hygiene be performed? The LPN/UM stated it should be before and after all care. She then…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-11-02 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to consistently document the administration of a treatment in the electronic Treatment Administration Record (eTAR) in accordance with the facility policy. This deficient practice was identified for 1 of 2 residents (Resident # 29) reviewed for nutrition and for 2 of 3 residents (Residents #90 and #195) reviewed for urinary catheter and was evidenced 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 registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-11-02 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, it was determined that the facility failed to accurately complete an Annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care for a resident. This deficient practice was identified for 1 of 25 residents reviewed (Resident #73) and was evidenced by the following: Review of the 08/07/22 Annual MDS for Resident #73 reflected in Section C Cognitive Patterns, that Subsections C0100, C0200, C0300, C0400, C0500 C0600, C0700, C0900, and C1000 were not assessed. The MDS further reflected in Section Q Participation and Goal Setting that Subsections Q0100, Q0300, Q0490, Q0500, Q0550 were not assessed. Review of Section Z Assessment Administration in subsection that Subsection Z0400 Signature of Persons Completing the Assessment reflected that the MDS Coordinator completed Sections C and Q. During an interview with the surveyor on 11/01/22 at 9:01 AM, the MDS Coordinator stated that at the time the MDS assessment was completed, the facility did not have a Social Worker who would usually completed Sections C, D and Q of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to ATLAS HEALTHCARE — 29 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.6 | +0.4 vs chain |
| Health inspection | 4 of 5 | 3.1 | +0.9 vs chain |
| Staffing | 4 of 5 | 2.3 | +1.7 vs chain |
| Quality measures | 3 of 5 | 4.4 | -1.4 vs chain |
The other 28 homes this chain runs (chain average 3.6★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| MYSTIC MEADOWS HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 11/01/2023 |
| COPPER NJ TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/01/2023 |
| GOLD NJ TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/01/2023 |
| MALT FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/01/2023 |
| NJ MAZEL PARENTCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/01/2023 |
| NJ NOBLE PARENTCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/01/2023 |
| SGS 2010 FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/01/2023 |
| SILVER NJ TR | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/01/2023 |
| TYH 2017 TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/01/2023 |
| MEISNER, ROBERT | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/01/2023 |
| EICKE, MARY JANE | Individual | W-2 MANAGING EMPLOYEE | — | since 11/01/2023 |
| GOLDBERGER, SHLOMO | Individual | W-2 MANAGING EMPLOYEE | — | since 11/01/2023 |
| DASONDI, VIVEKKUMAR | Individual | CORPORATE DIRECTOR | — | since 11/01/2023 |
| BAK, PINCHOS | Individual | CORPORATE OFFICER | — | since 11/01/2023 |
9 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $592K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NJ
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Jersey Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 315456. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-10, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.