Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

MYSTIC MEADOWS REHABILITATION AND NURSING CENTER

LITTLE EGG HARBOR TW, NJ · 130 certified beds · Last Life Safety survey December 10, 2025

CMS Certification Number 315456 · first certified September 1999

Ownership

Operated by ATLAS HEALTHCARE · For profit - Limited Liability company

Ownership changed November 1, 2023 (change of ownership)from LEH OPERATING LLC

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within NJ

27 citations — more than 89% of the 348 certified nursing homes in NJ. Compared within NJ rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 14 citations; the earlier surveys in the window averaged 6.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens March 2027 — about 6 months from now. This facility’s last Life Safety survey was December 2025. Facilities in NJ are typically surveyed 16–20 months after the last one (median 17), measured over 431 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

7 of the 27 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 27 Life Safety citations above. The Physical Environment Index

F-0584 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.
F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in NJ, and nationally. Surveyors differ markedly between states, so the NJ figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	27
Median facility in NJ	15
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
November 2, 2022	7
July 3, 2024	6
December 10, 2025	14

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	3	2025-12-10
K-0353	Inspect, test, and maintain automatic sprinkler systems.	2	2025-12-10
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	2	2024-07-03
K-0293	Have properly located and lighted "Exit" signs.	2	2025-12-10
E-0026	Establish roles under a Waiver declared by secretary.	1	2025-12-10
K-0923	Have proper medical gas storage and administration areas.	1	2024-07-03
E-0013	Develop Emergency Preparedness policies and procedures.	1	2025-12-10
K-0222	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	1	2025-12-10

What the citations cover

Citations by CMS category

Emergency Preparedness Deficiencies 7
Gas, Vacuum, and Electrical Systems Deficiencies 7
Egress Deficiencies 5
Smoke Deficiencies 5
Other 3

Citations by CMS category
Category	Citations
Emergency Preparedness Deficiencies	7
Gas, Vacuum, and Electrical Systems Deficiencies	7
Egress Deficiencies	5
Smoke Deficiencies	5
Services Deficiencies	2
Miscellaneous Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

December 10, 2025 — 14 citations

Citations issued on December 10, 2025
Tag	What the surveyor checks	Status
E-0006	Conduct risk assessment and an All-Hazards approach.	Deficient, Provider has date of correction (January 5, 2026)
E-0013	Develop Emergency Preparedness policies and procedures.	Deficient, Provider has date of correction (January 5, 2026)
E-0018	Establish procedures for tracking staff and patients during an emergency.	Deficient, Provider has date of correction (January 5, 2026)
E-0022	Establish policies and procedures for sheltering.	Deficient, Provider has date of correction (January 5, 2026)
E-0024	Establish policies and procedures for volunteers.	Deficient, Provider has date of correction (January 5, 2026)
E-0026	Establish roles under a Waiver declared by secretary.	Deficient, Provider has date of correction (January 5, 2026)
K-0222	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	Deficient, Provider has date of correction (January 5, 2026)
K-0271	Have exits that are accessible at all times.	Deficient, Provider has date of correction (January 5, 2026)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (January 5, 2026)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (January 5, 2026)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (January 5, 2026)
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	Deficient, Provider has date of correction (January 5, 2026)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (January 5, 2026)
K-0921	Ensure that testing and maintenance of electrical equipment is performed.	Deficient, Provider has date of correction (January 5, 2026)

July 3, 2024 — 6 citations

Citations issued on July 3, 2024
Tag	What the surveyor checks	Status
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (August 8, 2024)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (August 8, 2024)
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	Deficient, Provider has date of correction (August 8, 2024)
K-0911	Meet requirements for the installation and maintenance of electrical systems.	Deficient, Provider has date of correction (August 8, 2024)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (August 8, 2024)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (August 8, 2024)

November 2, 2022 — 7 citations

Citations issued on November 2, 2022
Tag	What the surveyor checks	Status
E-0030	List the names and contact information of those in the facility.	Deficient, Provider has date of correction (November 23, 2022)
K-0281	Install proper backup exit lighting.	Deficient, Provider has date of correction (December 28, 2022)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (November 28, 2022)
K-0341	Install a fire alarm system that can be heard throughout the facility.	Deficient, Provider has date of correction (December 15, 2022)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (December 15, 2022)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (November 28, 2022)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (December 15, 2022)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.