MYSTIC MEADOWS REHAB & NURSING CENTER

Nursing Home Inspector

151 NINTH AVENUE
TUCKERTON, NJ 08087
Ocean County
Phone: 609-294-3200
Provider Number: 315456
Last Inspection: 03/21/2017

About the Nursing Home

Number of Beds: 120
Number of Residents: 107
Beds Available: 13
Percent Occupancy: 89%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Partnership
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

19

Facility
8

County
11

NJ
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

19

2017
8

2016
20

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

3/21/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 5/15/2017
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 5/15/2017
 
Failed To: 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. Isolated : Minimal 3 5/15/2017
 
Failed To: Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. Isolated : Minimal 3 5/15/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 5/15/2017
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Pattern : Minimal 4 5/15/2017
 

2/11/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Minimal 4 3/7/2016
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Pattern : Minimal 4 3/7/2016
 

1/16/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Make sure that a working call system is available in each resident's room or bathroom and bathing area. Isolated : Minimal 3 3/1/2015
 
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 3/1/2015
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 3/1/2015
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 3/1/2015
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Pattern : Minimal 4 3/1/2015
 
Failed To: Make sure that all required doctor visits are made personally. Pattern : Minimal 4 3/1/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

No Complaint Deficiencies Reported

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg NJ State Avg
Number of Residents 107 112.31 121.28
Registered Nurses 0.69 0.87 0.98
Licensed Practical / Vocational Nurses 0.72 0.91 0.82
Certified Nursing Assistants 1.98 2.12 2.25
Total Staff Hours 3.38 3.90 4.05

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% NJ State Avg%
of high risk long-stay residents with pressure ulcers 9 4 6
of long-stay residents assessed and appropriately given the pneumococcal vaccine 100 95 95
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 99 96 96
of long-stay residents experiencing one or more falls with major injury 2 2 2
of long-stay residents who have depressive symptoms 1 0 1
of long-stay residents who lose too much weight 5 7 6
of long-stay residents who received an antianxiety or hypnotic medication 28 26 20
of long-stay residents who received an antipsychotic medication 12 9 11
of long-stay residents who self-report moderate to severe pain 4 2 2
of long-stay residents who were physically restrained 0 1 0
of long-stay residents whose ability to move independently worsened 24 13 14
of long-stay residents whose need for help with daily activities has increased 14 10 11
of long-stay residents with a catheter inserted and left in their bladder 0 0 1
of long-stay residents with a urinary tract infection 0 2 2
of low risk long-stay residents who lose control of their bowels or bladder 51 46 39
of short-stay residents assessed and appropriately given the pneumococcal vaccine 100 84 89
of short-stay residents who had an outpatient emergency department visit 16 12 9
of short-stay residents who made improvements in function 69 66 70
of short-stay residents who newly received an antipsychotic medication 4 1 1
of short-stay residents who self-report moderate to severe pain 2 7 6
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 95 82 87
of short-stay residents who were rehospitalized after a nursing home admission 15 25 22
of short-stay residents who were successfully discharged to the community 53 53 56
of short-stay residents with pressure ulcers that are new or worsened 0 0 0