Mystic Meadows Rehabilitation and Nursing Center

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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; [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteComplaint #: 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: [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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; [...]

Inspectors wroteBased 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. [...]