Cycle 1
Health 2024-07-03 · Fire 2024-07-03
4 health deficiencies
Top issue: Infection Control (1 deficiency)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Little Egg Harbor Tw, NJ
Mystic Meadows Rehabilitation And Nursing Center
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
151 Ninth Avenue, Little Egg Harbor Tw, NJ
(609) 294-3200
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
130
Certified beds
Average residents
103
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Atlas Healthcare
Operator or chain grouping
Approved since
1999-09-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
28 facilities
Chain averages 4 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.44
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.13
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.14
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.70
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.37
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
3.91
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,182
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.21
Composite VBP score used to determine payment impact.
Payment multiplier
0.9826
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.97
Baseline 18.67% · Performance 19.59% · Measure score 3.97 · Achievement 3.97 · Improvement 0
Healthcare-associated infections
0.79
Baseline 6.90% · Performance 7.60% · Measure score 0.79 · Achievement 0.79 · Improvement 0
Total nurse turnover
1.77
Baseline 76.30% · Performance 64.60% · Measure score 1.77 · Achievement 0 · Improvement 1.77
Adjusted total nurse staffing
1.95
Baseline 3.24 hours · Performance 3.63 hours · Measure score 1.95 · Achievement 1.95 · Improvement 1.06
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.73% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 135 · Observed rate 8.89% · Lower 95% interval 6.77% |
| Discharge to community | 49.28% |
50.57%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 117 · Observed rate 41.88% · Lower 95% interval 42.53% |
| Medicare spending per beneficiary | 1.34 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 131 · Denominator 131 |
| Falls with major injury | 1.53% |
0.77%
0.8 pts worse
|
Numerator 2 · Denominator 131 |
| Discharge self-care score | 60% |
53.69%
6.3 pts better
|
Numerator 45 · Denominator 75 |
| Discharge mobility score | 42.67% |
50.94%
8.3 pts worse
|
Numerator 32 · Denominator 75 |
| Pressure ulcers or injuries, new or worsened | 2.29% |
2.29%
About the same
|
Numerator 3 · Denominator 131 · Adjusted rate 2.49% |
| Healthcare-associated infections requiring hospitalization | 7.6% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 81 · Observed rate 8.64% · Lower 95% interval 4.73% |
| Staff COVID-19 vaccination coverage | 3.67% |
8.2%
4.5 pts worse
|
Numerator 4 · Denominator 109 |
| Staff flu vaccination coverage | 90% |
42%
48 pts better
|
Numerator 135 · Denominator 150 |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 50 · Denominator 75 |
| Transfer of health information to provider | 98.84% |
95.95%
2.9 pts better
|
Numerator 85 · Denominator 86 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 39.51% |
25.2%
14.3 pts better
|
Numerator 32 · Denominator 81 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.1
0.3 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.8 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.1
0.4 pts worse
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 70.9% |
93.0%
22.1 pts worse
|
93.4%
22.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 72.6% · Q2 70.8% · Q3 72.8% · Q4 67.1% · 4Q avg 70.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.8% |
97.2%
1.4 pts worse
|
95.5%
0.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.9% |
2.4%
4.5 pts worse
|
3.3%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 7.9% · Q3 6.5% · Q4 5.9% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 25.6% |
11.4%
14.2 pts worse
|
11.4%
14.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 41.9% · Q3 25.0% · Q4 19.7% · 4Q avg 25.6% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
4.6%
1.8 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 3.6% · Q4 6.2% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.4% |
19.0%
11.4 pts worse
|
19.6%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 32.9% · Q3 27.6% · Q4 30.9% · 4Q avg 30.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.7% |
13.5%
14.2 pts worse
|
16.7%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.8% · Q2 30.5% · Q3 25.0% · Q4 26.7% · 4Q avg 27.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 3.3% |
9.8%
6.5 pts better
|
16.3%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 0.0% · Q3 2.6% · Q4 4.6% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.0% |
9.7%
5.7 pts better
|
14.9%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 6.0% · Q3 1.2% · Q4 2.5% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
0.8%
0.5 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.1% |
15.9%
15.2 pts worse
|
19.8%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.7% · Q2 31.1% · Q3 31.6% · Q4 24.2% · 4Q avg 31.1% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
6.0%
3 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 1.2% · Q3 4.4% · Q4 4.1% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 65.1% |
78.7%
13.6 pts worse
|
81.7%
16.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 60.2% · Q2 69.9% · Q3 63.9% · Q4 66.4% · 4Q avg 65.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.3% |
8.2%
1.1 pts worse
|
12.0%
2.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.3% · Observed 10.5% · Expected 12.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.2%
0.2 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.1% |
80.1%
2 pts better
|
79.7%
2.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.4% |
25.4%
3 pts worse
|
23.9%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.4% · Observed 33.3% · Expected 28.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-02 · Fire 2022-11-02
2 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2020-03-12 · Fire 2020-03-12
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-08
F · Potential for more than minimal harm
2024-07-03
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-08-08
F · Potential for more than minimal harm
2024-07-03
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-08-08
F · Potential for more than minimal harm
2024-07-03
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-08-08
F · Potential for more than minimal harm
2024-07-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-08
F · Potential for more than minimal harm
2024-07-03
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-08-08
F · Potential for more than minimal harm
2022-11-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-15
E · Potential for more than minimal harm
2022-11-02
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2022-12-28
E · Potential for more than minimal harm
2022-11-02
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-11-28
E · Potential for more than minimal harm
2022-11-02
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-12-15
E · Potential for more than minimal harm
2022-11-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-15
D · Potential for more than minimal harm
2022-11-02
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2022-11-23
D · Potential for more than minimal harm
2022-11-02
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-11-28
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-07-03
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-08
D · Potential for more than minimal harm
2024-07-03
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-08-08
D · Potential for more than minimal harm
2024-07-03
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-08
D · Potential for more than minimal harm
2024-07-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-08
E · Potential for more than minimal harm
2022-11-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-11-02
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2022-11-28
E · Potential for more than minimal harm
2020-03-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2020-05-18
E · Potential for more than minimal harm
2020-03-12
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2020-05-18
D · Potential for more than minimal harm
2020-03-12
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2020-05-18
D · Potential for more than minimal harm
2020-03-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2020-05-18
D · Potential for more than minimal harm
2020-03-12
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2020-05-18
D · Potential for more than minimal harm
2020-03-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-05-18
Penalties and ownership
What sits behind the stars
Ownership
Mystic Meadows Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Bak, Pinchos
Corporate Officer · Individual
Copper Nj Trust
5% Or Greater Indirect Ownership Interest · Organization
Dasondi, Vivekkumar
Corporate Director · Individual
Eicke, Mary Jane
W-2 Managing Employee · Individual
Gold Nj Trust
5% Or Greater Indirect Ownership Interest · Organization
Goldberger, Shlomo
W-2 Managing Employee · Individual
Malt Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Meisner, Robert
5% Or Greater Indirect Ownership Interest · Individual
Nj Mazel Parentco LLC
5% Or Greater Indirect Ownership Interest · Organization
Nj Noble Parentco LLC
5% Or Greater Indirect Ownership Interest · Organization
Sgs 2010 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Silver Nj Tr
5% Or Greater Indirect Ownership Interest · Organization
Tyh 2017 Trust
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Seacrest Rehabilitation And Healthcare Center
Little Egg Harbor Tw, NJ
3-star overall rating with 2-star inspections with 11 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Manahawkin Health And Rehabilitation Center
Manahawkin, NJ
1-star overall rating with 1-star inspections with 22 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#3
Southern Ocean Center
Manahawkin, NJ
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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