Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bishop Mccarthy Center For Rehab & Healthcare during CMS and state inspections, most recent first.
A resident with cognitive and physical impairments was sent unaccompanied to an out-of-state medical appointment without confirmation that an attendant would be present. Facility staff assumed an aide would be provided based on prior communications, but did not verify this for the specific appointment. The resident eloped from the appointment location, was missing for over a day, and was later hospitalized for acute kidney injury due to dehydration.
A facility failed to document medication administration in the MAR immediately after administration, as observed during a survey. An LPN admitted to not following the policy, keeping track of medications on a census sheet instead. The Unit Manager and DON confirmed the policy requires immediate documentation, and 26 residents' medications were not signed out on the MAR, despite being administered.
The facility failed to provide necessary respiratory care for a resident with a tracheostomy by not having the correct size emergency tracheostomy kit at the bedside and not updating treatment orders to reflect the use of disposable inner cannulas.
The facility failed to serve hot and cold foods at acceptable temperatures for residents on the Third Floor Dining Room during lunch. The Dietary Director (DD) observed that the temperatures of hot foods dropped significantly from the kitchen to the dining room, and the cold food item was above the acceptable range. The facility's policy required hot foods to be above 135°F and cold foods at or below 41°F, which was not maintained.
The facility failed to maintain kitchen equipment and areas, leading to potential microbial growth and cross-contamination. Observations included wet nested pans, dirty cutting boards, debris in the ice machine, and uncovered food-related items. The Dietary Director acknowledged these issues, which were not in line with the facility's policies.
The facility failed to follow infection control practices during meal tray pass on the Third Floor unit. A CNA handled meal trays and trash without performing hand hygiene between tasks, and the soap and paper towel dispensers were empty. Interviews with staff confirmed the deficiency, highlighting a significant lapse in infection control practices.
The facility failed to maintain medication and treatment carts in a sanitary manner, with visible human hair found in the wheels of multiple carts on both the Subacute and North Hall units. Staff interviews revealed confusion about cleaning responsibilities, and the facility lacked a formal policy for cart cleaning.
The facility failed to obtain a physician's order specifying the application and removal times for an orthotic device and did not develop a comprehensive care plan for a resident with limited range of motion. The resident wore the brace continuously without a clear schedule for its removal, and the care plan did not include any information about the brace.
The facility failed to maintain accurate medical records for a resident with end-stage renal failure, documenting blood pressures in the left arm despite orders to avoid it due to an AV fistula. Staff admitted to documentation errors, and the facility's policy on accurate record-keeping was not followed.
Failure to Ensure Supervision During Offsite Medical Appointment Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and significant physical limitations was sent unaccompanied to an out-of-state medical appointment. The resident required assistance with all activities of daily living, had a history of neurological and psychiatric conditions, and was assessed as needing accompaniment for offsite appointments. Despite this, the facility arranged for transportation through an outside provider without confirming that an attendant would be present during the appointment. Documentation and interviews revealed that staff assumed an aide would be provided based on previous communications and prior appointments, but no direct confirmation was obtained for the specific appointment in question. On the day of the appointment, the resident was transported by medical transport arranged by the outside provider. Later that day, the facility was notified by the provider's office that the resident could not be located. The resident's wheelchair was found, and a search was initiated. The resident was eventually found over a day later at a nearby park, having eloped from the appointment location. The resident was subsequently hospitalized for five days with an acute kidney injury likely due to dehydration. Interviews with facility staff, including the unit secretary, unit manager, and DON, confirmed that there was no documented verification that an attendant would be present for the resident's appointment. The process for determining the need for accompaniment was handled verbally, and there was no written confirmation or follow-up to ensure the resident's safety during offsite appointments. The lack of confirmation and failure to provide adequate supervision directly led to the resident's elopement and subsequent hospitalization.
Failure to Document Medication Administration in MAR
Penalty
Summary
The facility failed to adhere to professional standards of quality in documenting medication administration in the electronic Medication Administration Record (MAR). This deficiency was identified during a survey when an LPN was observed administering medications to residents but not signing them out on the MAR immediately after administration. The LPN admitted to not following the facility's policy, which requires medications to be signed out on the MAR after each administration. Instead, the LPN kept track of administered medications on a census sheet with the intention of updating the MAR after completing the medication pass. The surveyor's review of the MAR screen revealed that 26 residents' names were highlighted in pink, indicating that their medications were not signed out, despite being administered. The LPN's actions were confirmed by the Unit Manager and the Director of Nursing, who both stated that the facility's policy mandates immediate documentation on the MAR after medication administration. The failure to document medications promptly could lead to assumptions that medications were not given, posing a risk to resident safety.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide the necessary respiratory care and services for a resident with a tracheostomy. The resident, who was admitted with diagnoses including cerebral infarction and chronic respiratory failure, required extensive to total care for all activities of daily living. During a tour, the surveyor observed that the resident did not have an emergency tracheostomy kit with the correct size tracheostomy tube at the bedside, which is essential in case of decannulation. The resident's tracheostomy size had changed following surgery, but the emergency kit still contained the old size, and the treatment order for tracheostomy care was not updated to reflect the new size or the correct procedure for disposable inner cannulas. Interviews with the nursing staff revealed that the emergency tracheostomy kit contained the wrong size tracheostomy tube, and the treatment order to clean the inner cannula every shift was inaccurate because the resident had a disposable inner cannula that should be replaced, not cleaned. The Licensed Practical Nurses (LPNs) and the Director of Nursing (DON) confirmed that the emergency kit should have the correct size tracheostomy tube or a size smaller and that the treatment order needed clarification. The staff acknowledged that the current order did not specify the correct procedure for managing the disposable inner cannula. The facility's policies on emergency tracheostomy care and care of a tracheostomy resident were not followed. The policies required that an emergency tracheostomy set up, including a tracheostomy care kit, ambu bag, and a smaller size tracheostomy tube, be available at the resident's bedside. The failure to update the emergency kit and treatment orders after the resident's tracheostomy size changed led to the deficiency in providing appropriate respiratory care for the resident.
Failure to Maintain Acceptable Food Temperatures
Penalty
Summary
The facility failed to serve hot and cold foods at acceptable temperatures for the residents on the Third Floor Dining Room during the lunch meal service. The surveyor observed the Dietary Director (DD) calibrate a digital thermometer and test the food temperatures on a test tray. The temperatures of the hot foods (sliced roast beef, mashed potatoes with gravy, and mixed vegetables) were within acceptable ranges when plated in the kitchen but dropped significantly by the time they were delivered to the Third Floor. The cold food item, individual cups of pineapple chunks, was also above the acceptable temperature range both in the kitchen and upon delivery to the Third Floor. The DD acknowledged that the temperatures of the hot foods should have been maintained between 120-130 degrees Fahrenheit and that the cold food should have been 41 degrees Fahrenheit or below. The facility's policy on food temperatures stated that hot food items should not fall below 135 degrees Fahrenheit after cooking and that cold food items should be maintained and served at 41 degrees Fahrenheit or below. The deficiency was identified through observation, interview, and review of the facility's documentation, which confirmed that the food temperatures were not maintained as per the facility's policy, potentially leading to foodborne illnesses and food complaints.
Failure to Maintain Kitchen Equipment and Areas
Penalty
Summary
The facility failed to maintain equipment and kitchen areas in a manner to prevent microbial growth and cross-contamination. During a kitchen tour, the surveyor observed several deficiencies: wet nested pans with clear liquid between them, cutting boards with smudges, stains, and scratches, and an ice machine with pink and black debris on the inside plastic guard. Additionally, a deli slicer had white and pink debris on various parts, the bottom oven had black and brown greasy debris, and an uncovered box of plastic wrap was found in the cook area. Coffee filters were also found uncovered and exposed to air on the utensil rack. The Dietary Director (DD) acknowledged each of these issues and stated the importance of proper cleaning and sanitization for infection control. The facility's policies on food preparation, handling, and equipment cleaning were reviewed, revealing that the observed practices did not align with the established procedures. The administration team was informed of these kitchen concerns during a meeting with the surveyors.
Failure to Perform Hand Hygiene During Meal Tray Pass
Penalty
Summary
The facility failed to follow appropriate infection control practices and perform hand hygiene during meal tray pass on the Third Floor unit. The surveyor observed a CNA handling meal trays and trash without performing hand hygiene between tasks. Specifically, the CNA lifted the trash can lid with her hand, discarded trash, and then proceeded to handle meal trays and food items for multiple residents without washing her hands. The CNA attempted to wash her hands at the sink, but the soap and paper towel dispensers were empty, leading her to continue serving residents without proper hand hygiene. Interviews with the CNA, LPN, LPN Unit Manager, ADON, and DON confirmed that the CNA did not perform hand hygiene correctly. Each staff member acknowledged the importance of hand hygiene in preventing cross-contamination and infection. The facility's policies on hand hygiene and assisting residents with meals were reviewed, revealing that hand hygiene should be performed before and after patient contact, before serving food, and after contact with soiled items. The CNA had attended an infection control in-service training, which emphasized the importance of following facility policies and performing hand hygiene. The facility's failure to ensure proper hand hygiene during meal tray pass was a clear violation of their infection control policies. The CNA's actions, combined with the lack of available soap and paper towels, contributed to the deficiency. The observations and interviews highlighted a significant lapse in infection control practices, which could potentially lead to cross-contamination and infection among residents.
Sanitation Deficiency in Medication and Treatment Carts
Penalty
Summary
The facility failed to maintain medication and treatment carts in a sanitary manner on both the Subacute and North Hall units. The surveyor observed visible amounts of human hair built up in the wheels of multiple medication and treatment carts. Specifically, on the North Hall unit, human hair was found in all four wheels of the front medication cart and both treatment carts. Similarly, on the Subacute unit, human hair was observed in the wheels of both medication carts and both treatment carts. These observations were made over two consecutive days during the surveyor's inspection of the facility's carts. Interviews with various staff members revealed inconsistencies and confusion regarding the responsibility for cleaning the medication and treatment carts. An LPN believed that housekeeping was responsible for cleaning the carts overnight, while another LPN and an RN stated that nurses cleaned the outside surfaces of the carts before and after their shifts. The housekeeper for the North Hall and Subacute units confirmed that housekeeping was responsible for cleaning the outside of the carts but was unsure who cleaned the wheels. The Director of Housekeeping and Laundry (DHL) stated that housekeeping conducted thorough cleaning of the carts quarterly, but this schedule had not been completed for the current year. The facility lacked a formal policy and procedure for the cleaning of medication and treatment carts. The DHL provided a typed document outlining a cleaning procedure, but it was not an official policy. The Licensed Nursing Home Administrator (LNHA) confirmed that the facility did not have a policy and procedure for cart cleaning and had instructed the DHL to create a document to present to the surveyor. The facility's existing policy on cleaning and disinfection of care items did not include specific instructions for medication and treatment carts. The surveyor's findings were confirmed by the DHL, who acknowledged the presence of human hair in the wheels and the importance of cleaning them for infection control.
Failure to Obtain Physician's Order and Develop Care Plan for Orthotic Device
Penalty
Summary
The facility failed to obtain a physician's order specifying the application and removal times for an orthotic device and did not develop a comprehensive care plan for the use of a hinged brace for a resident. The resident, who had diagnoses including cerebral infarction, traumatic brain injury, and limited range of motion in the lower extremities, was observed wearing the brace continuously without a clear schedule for its removal. The care plan did not include any information about the brace, and the physician's order was incomplete, lacking details on when the brace should be applied and removed. Interviews with staff revealed that the resident wore the brace 24 hours a day, only removing it for showers and skin checks, but there was no formal documentation or physician's order to guide this practice. The Certified Nursing Assistant (CNA) and Licensed Practical Nurse (LPN) confirmed that the brace was worn continuously and that the order was incomplete. The Director of Rehabilitation and the treating Physical Therapist acknowledged that the order needed to be revised to include specific instructions for the brace's use. The Director of Nursing (DON) confirmed that the facility's policy required a physician's order for orthotic devices and that the care plan should include the usage of such devices. The facility's policy also indicated that the comprehensive care plan should be updated to reflect any changes in status, goals, and recommendations related to the orthotic device. However, these steps were not followed, leading to the deficiency in care for the resident.
Inaccurate Medical Records for Dialysis Patient
Penalty
Summary
The facility failed to maintain accurate and consistent medical records for a resident with end-stage renal failure who required hemodialysis. The resident's care plan and physician's orders specified that no blood pressures or venipunctures should be performed on the resident's left arm due to the presence of an AV fistula. Despite this, the facility's documentation indicated that blood pressures were taken in the resident's left arm on multiple occasions. Interviews with the resident and staff confirmed that blood pressures were occasionally taken in the left arm, and staff admitted to documentation errors. The Licensed Practical Nurse (LPN) and the Registered Nurse/Unit Manager (RN/UM) acknowledged the importance of accurate documentation, especially given the resident's left arm restrictions. The Director of Nursing (DON) also confirmed that the nurses should have documented the correct arm for blood pressure measurements. The facility's policy emphasized the need for complete and accurate documentation to facilitate communication among the interdisciplinary team. However, the facility failed to adhere to this policy, resulting in inconsistent and inaccurate medical records for the resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 143 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Vineland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| New Jersey Veterans Memorial Vineland | 1.5 mi | ★★★★★ | 2 | 1 |
| Autumn Lake Healthcare At Vineland | 2 mi | ★★★★★ | 0 | 0 |
| Millville Center | 4.8 mi | ★★★★★ | 2 | 2 |
| Big Oak Rehabilitation And Healthcare Center | 5.9 mi | ★★★★★ | 8 | 0 |
| South Jersey Extended Care | 11.5 mi | ★★★★★ | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.