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Health Inspection Summary

Bishop McCarthy Center for Rehab & Healthcare

1045 E Chestnut Ave

Vineland, NJ 08360

(856) 692-2850

Deficiency Category	Inspection Date: 3/28/24 Complaint Reporting Period: 4/1/24 - 3/31/25	Inspection Date: 1/4/22 Complaint Reporting Period: 4/1/23 - 3/31/24	Inspection Date: 2/3/20 Complaint Reporting Period: 4/1/22 - 3/31/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies	0	2	0
Quality of Life and Care Deficiencies	2	2	2
Infection Control Deficiencies	1	1	1
Resident Assessment and Care Planning Deficiencies	2	0	1
Nursing and Physician Services Deficiencies	0	0	0
Resident Rights Deficiencies	0	3	0
Nutrition and Dietary Deficiencies	2	2	0
Pharmacy Service Deficiencies	0	0	1
Environmental Deficiencies	1	0	0
Administration Deficiencies	0	0	0

Detailed result for inspection on 3/28/24

Date of last standard health inspection:	3/28/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25	9/26/24Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25	No infection control inspections
Total number of Health Deficiencies for this nursing home:	8
Average number of Health Deficiencies in New Jersey:	8
Average number of Health Deficiencies in the United States:	9.6

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide 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.	3/28/24	5/12/24	2 - Minimal harm or potential for actual harm	Few
Provide safe and appropriate respiratory care for a resident when needed.	3/28/24	5/12/24	2 - Minimal harm or potential for actual harm	Some

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	3/28/24	5/12/24	2 - Minimal harm or potential for actual harm	Some

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure services provided by the nursing facility meet professional standards of quality.	9/26/24	11/15/24	2 - Minimal harm or potential for actual harm	Some
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	3/28/24	5/12/24	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
No Resident Rights Deficiencies were found during this inspection period.

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	3/28/24	5/12/24	2 - Minimal harm or potential for actual harm	Some
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.	3/28/24	5/12/24	2 - Minimal harm or potential for actual harm	Some

Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.

Environmental Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.	3/28/24	5/12/24	2 - Minimal harm or potential for actual harm	Some

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 1/4/22

Date of last standard health inspection:	1/4/22Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24	3/28/24Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24	No infection control inspections
Total number of Health Deficiencies for this nursing home:	10
Average number of Health Deficiencies in New Jersey:	6.1
Average number of Health Deficiencies in the United States:	9.4

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	1/4/22	2/1/22	2 - Minimal harm or potential for actual harm	Few
Respond appropriately to all alleged violations.	1/4/22	2/1/22	2 - Minimal harm or potential for actual harm	Few

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	1/4/22	2/1/22	2 - Minimal harm or potential for actual harm	Few
Provide safe and appropriate respiratory care for a resident when needed.	1/4/22	2/1/22	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	1/4/22	3/17/22	2 - Minimal harm or potential for actual harm	Few

Resident Assessment and Care Planning Deficiencies
No Resident Assessment and Care Planning Deficiencies were found during this inspection period.

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Reasonably accommodate the needs and preferences of each resident.	1/4/22	2/1/22	2 - Minimal harm or potential for actual harm	Few
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.	1/4/22	2/1/22	1 - Potential for minimal harm	Some
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.	1/4/22	2/1/22	1 - Potential for minimal harm	Many

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	1/4/22	2/1/22	2 - Minimal harm or potential for actual harm	Many
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.	1/4/22	2/1/22	2 - Minimal harm or potential for actual harm	Some

Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 2/3/20

Date of last standard health inspection:	2/3/20Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23	No complaint inspections
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23	No infection control inspections
Total number of Health Deficiencies for this nursing home:	5
Average number of Health Deficiencies in New Jersey:	3.8
Average number of Health Deficiencies in the United States:	8.7

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide safe and appropriate respiratory care for a resident when needed.	2/3/20	3/4/20	2 - Minimal harm or potential for actual harm	Few
Provide care and assistance to perform activities of daily living for any resident who is unable.	2/3/20	3/4/20	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	2/3/20	3/4/20	2 - Minimal harm or potential for actual harm	Few

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure each resident receives an accurate assessment.	2/3/20	3/4/20	1 - Potential for minimal harm	Some

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
No Resident Rights Deficiencies were found during this inspection period.

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.	2/3/20	3/4/20	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure services provided by the nursing facility meet professional standards of quality.	9/26/24	11/15/24	2 - Minimal harm or potential for actual harm	Some
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.	3/28/24	5/12/24	2 - Minimal harm or potential for actual harm	Some

Infection control inspection deficiencies in the past 3 years
This nursing home has not had any infection control inspections in the past 3 years.

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