Bishop McCarthy Center for Rehab & Healthcare

Inspectors wroteCOMPLAINT #2572162 Based on observations, interviews, medical record review, and review of other pertinent facility documentation on 7/31/25 and 8/1/25, it was determined that the facility failed to provide adequate supervision for a resident with cognitive impairment who required assistance with all activities of daily living and accompaniment to outside doctor's appointments and was sent to an out-of-state doctor's appointment and eloped. This deficient practice was identified for 1 of 3 residents reviewed for accidents (Resident #1). On 7/23/25 at 10:15 A.M., Resident #1 was sent to an out-of-state (OOS) doctor's appointment unaccompanied via medical transport. At 4:00 P.M., the facility received a telephone call from the OOS provider's office that Resident #1 could not be located. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 06/06/2025 from 09:54 to 10:27 AM the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. Upon entry to the kitchen the surveyor went to observe the high temperature dish machine that was actively washing dishes at the time. The surveyor requested to see the dish machine temperature log. The June 2025 Dish Machine Temperature Log indicated that on 6/6/25 at breakfast the high temperature dish machine had the following temperatures prior to washing dishes: Wash = 180 and Rinse = 16 (confirmed by FSD to be 160 degrees Fahrenheit(F)). [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to develop and implement a comprehensive plan of care for a resident on long-term use of anti-depressant and anti-psychotic medications. This deficient practice was identified for 1 of 4 residents (Resident #81) reviewed for behavioral and emotional care and was evidenced by the following: On 6/6/2025 at 10:36 AM, during the initial tour of the facility, Resident #81 was observed by Surveyor #1 resting in bed fully dressed but did not respond to the surveyor's greeting. On 6/9/2025 at 9:11 AM, Surveyor #2 observed the resident awake in bed and fully dressed. The resident did not engage in conversation with the surveyor. On 6/9/2025 at 11:00 AM, Surveyor #2 reviewed the electronic medical record for Resident #81. [...]

Inspectors wroteBased on observation, interview and record review, and review of other facility documentation, it was determined that the facility failed to; a) ensure proper administration of medication during medication pass observation for 1 of 4 residents observed (Resident #164); b) document the notification to the physician when a medication was not administered as ordered for 1 of 2 residents sampled for dialysis (Resident #24); c) administer pain medications within scheduled parameters on various shifts for 1 of 3 residents investigated for pain management (Resident #141); d) provide antibiotic therapy according to a physician's orders for 1 of 1 resident's reviewed for antibiotic therapy (Resident #222), in accordance with professional standards of practice. This deficient practice was evidenced as follows: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. [...]

Inspectors wroteComplaint # NJ181256 Based on observation, interview, review of closed medical records and review of other facility documentation, it was determined that the facility failed to provide a resident with pressure ulcers the necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcer development for 1 of 4 residents reviewed for pressure ulcers (Resident #222). The evidence was as follows: On 6/11/2025 at 12:37 PM, the surveyor reviewed the closed electronic medical records (EMR) for Resident #222 who had been discharged from the facility. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents it was determined that the facility failed to store medications securely in their packaging inside the medication cart. The deficient practice was identified for 2 of 8 medication carts reviewed under the Medication Storage task. The deficient practice was evidenced by the following: On 6/9/2025 at 12:00 PM, in the presence of Licensed Practical Nurse (LPN #1), the surveyor inspected the short hall medication cart. The surveyor found 3 loose tablets. LPN #1 stated that there should not be loose medications in the cart. On 6/9/2025 at 12:12 PM, in the presence of LPN #2, the surveyor inspected the long hall medication cart. The surveyor found 11 loose tablets. LPN #2 stated that there should not be loose medications in the cart because it was a safety hazard and sanitation issue. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to prevent the potential for cross contamination by not initiating and implementing Enhanced Barrier Precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms) for a resident with an infected wound in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of clinical practice. This deficient practice was identified for 1 of 5 residents (Resident #166) reviewed for pressure ulcers and was evidenced by the following: According to the CDC Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, dated 6/28/2024, EBP are recommended for residents with indwelling devices or wounds . [...]

Inspectors wroteComplaint #: NJ00175475 Based on observations, interviews, medical record review, and review of other pertinent facility documentation on 09/26/2024, it was determined that the facility failed to follow standards of clinical practice for documenting the administration of medication in the electronic Medication Administration Record (MAR). The facility also failed to follow its policy titled Administering Medications. This deficient practice was identified for 26 of 29 residents reviewed on MAR 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: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide the necessary respiratory care and services for 1 (one) of 2 (two) residents (Resident # 100) reviewed for respiratory services. This deficient practice was evidenced by the following: According to the admission Record (AR) Resident #100 was admitted to the facility with diagnoses that included, but were not limited to, cerebral infarction (stroke) and chronic respiratory failure. The quarterly Minimum Data Set (MDS), an assessment tool, dated 02/23/24, indicated that the resident was cognitively intact and required extensive to total care with all aspect of activities of daily living (ADLs). The MDS also indicated that the resident required tracheostomy care (a surgical opening in your neck that delivers oxygen to your lungs). [...]

Inspectors wroteComplaint: NJ171634 Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to serve hot and cold foods at an acceptable temperature for the residents. This deficient practice was identified on 1 of 3 nursing units (Third Floor Dining Room) during the lunch meal service. The deficient practice was evidenced by the following: On 03/27/24 at 11:15 AM, the surveyor met with the Dietary Director (DD) in the kitchen and informed her a temperature test tray was requested for the Third Floor. On 03/27/24 at 11:31 AM, the dining staff started plating trays for the food cart for the Third floor. The surveyor observed the DD calibrate a digital thermometer in a cup of ice water, and the temperature read 32 degrees Fahrenheit (F). [...]

Inspectors wroteBased on observation, interview, and review of facility documentation it was determined that the facility failed to maintain equipment and kitchen areas in a manner to prevent microbial growth and cross-contamination. This deficient practice was observed and evidenced by the following: On 03/18/24 from 09:43 AM until 10:33 AM, the surveyor toured the kitchen in the presence of the Dietary Director (DD) and observed the following: 1. On the clean pots and pans drying rack, there were two sets of two 4-inch long pans nested, with clear liquid between the pans. The DD acknowledged that the pans were wet nested and stated that it was important to make sure the pans were dried correctly for bacterial prevention. 2. On the clean pots and pans rack there were: two large red cutting boards with brown smudges and scratches; one white cutting board with brown stains, black smudges, and scratches; [...]

Inspectors wroteBased on observation, interviews, and review of facility documentation, it was determined that the facility failed to follow appropriate infection control practices and perform hand hygiene as indicated during meal tray pass for 1 of 3 units (Third Floor unit) observed. The deficient practice was evidenced as follows: On 03/18/24 the surveyor observed the following in the Dining area: At 11:52 AM, the Certified Nursing Assistant (CNA) approached the lidded trash can with a plastic dome plate cover and trash in her hand then lifted the trash can lid with her hand and discarded the trash into the can. The CNA went to the food cart, removed a meal tray from the cart and placed it in front of Resident #22. [...]

Inspectors wroteComplaint: NJ171634 Based on observations, interviews, and review of other facility documentation, it was determined the facility failed to maintain medication and treatment carts in a sanitary manner for 2 of 2 medication carts and 2 of 3 treatment carts on the Subacute unit, and 1 of 2 medication carts and 2 of 2 treatment carts on the North Hall unit. This deficient practice was evidence by the following: On 03/20/24 at 10:00 AM, the surveyor observed visible amounts of human hair built up in all 4 wheels of the North Hall Front medication cart. On 03/21/24 at 10:01 AM, the surveyor inspected all medication and treatment carts for the Subacute unit and observed the following: - Visible human hair in 2 of 4 wheels of the Even (side) Subacute medication cart. - Visible human hair in all 4 wheels on the Odd (side) Subacute medication cart. [...]

Inspectors wroteBased on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to a.) obtain a physician's order for application and removal times of an orthotic device and b.) develop a comprehensive care plan for the use of an orthotic brace for 1 of 3 residents (Resident # 153) reviewed for positioning/mobility. This deficient practice was evidenced by the following: The admission Record indicated that Resident #153 was admitted to the facility with diagnoses that included, but were not limited to, cerebral infarction (stroke), cyclist injured in a collision with car, and traumatic brain injury. [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to maintain medical records that were accurate and consistent for 1 of 32 (Resident # 89) medical records reviewed. This deficient practice was evidenced by the following: According to the admission Record, Resident #89 was admitted to the facility with diagnoses that included, but were not limited to, end stage renal failure. The admission Minimum Data Set (MDS), an assessment tool that facilitated a resident's care, dated 02/22/2024, reflected that the resident had moderate cognitive impairment and required moderate to dependent assistance with activities of daily living. The MDS also indicated that the resident received hemodialysis (process that filters waste, salts, and fluid from the blood when the kidneys are no longer healthy enough to do this work adequately). [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent foodborne illness. This deficient practice was evidenced by the following: On 12/10/2021 at 9:53 AM, the surveyors, accompanied by the Head [NAME] (HC) observed the following in the kitchen: 1. In the Dry Storage area on a lower shelf, (1) open bag of shell pasta and (2) open bags of rotini pasta did not have an open or use by dates. On the shelf above, (1) open bag of spaghetti wrapped in plastic wrap had no open or use by date. When interviewed the HC stated, We usually have an open and use by date on anything that is opened and not completely used. 2. In the Walk-In Refrigerator on a rear shelf, one half onion was observed in a plastic container. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to consistently serve foods at a safe and appetizing temperature. This deficient practice was evidenced by the following: On 12/14/2021 at 10:30 AM, the surveyor conducted the Resident Council Meeting with seven alert and oriented residents. 7 of 7 residents in attendance stated the food was often not served hot enough for their preference. The residents stated that less than warm meals occurred at all mealtimes. On 12/16/2021 at 11:15 AM, the surveyors entered the kitchen to monitor food temperatures for the lunch meal. At 11:30 AM, an interview was conducted with the [NAME] who confirmed that food temperatures are not obtained prior to food being placed into the steam table or prior to plating. [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to maintain the nurse call light within in reach of a resident. This deficient practice was identified for 1 of 25 sampled resident's, (Resident #86) and was evidenced by the following: During the initial tour on 12/10/2021 at 11:28 AM, the surveyor observed Resident #86's call light was wedged between the mattress and bedframe of the bed. The call light was observed to hang down towards the floor and was not accessible to the resident in this position. The call light was observed to be on the right side of the bed. According to the admission Record Resident #86 had the following diagnoses: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, muscle weakness and unspecified abnormalities of gait and mobility. [...]

Inspectors wroteBased on observation, interviews, review of medical records and other facility documentation, it was determined that the facility failed to report an elopement to the New Jersey Department of Health (NJDOH) in accordance state requirements for 1 of 1 resident reviewed for elopement, (Resident #73). This deficient practice was evidence by the following: According to the admission Record, Resident #73 was admitted to the facility with diagnoses that included but not limited to, Dementia, Major Depressive Disorder with behavior disturbance. A review of the most recent Minimum Data Set (MDS), an assessment tool used to manage care dated 11/3/21, revealed that Resident #73 had severe cognitive impairment and had a Wander Guard alarm bracelet (an alarm that will sound if the resident gets close to a door with the sensor) in place. [...]

Inspectors wroteBased on interview, record review and review of other facility documentation, it was determined that the facility failed to complete a thorough investigation of an elopement for 1 of 1 resident reviewed for elopement (Resident #73). The deficient practice was evidenced by the following: According to the admission Record, Resident #73 was admitted to the facility with diagnoses that included but not limited to, Dementia, Major Depressive Disorder with behavior disturbance. A review of the most recent Minimum Data Set (MDS), an assessment tool used to manage care, dated 11/3/21, revealed that Resident #73 had severe cognitive impairment and had a Wander Guard alarm bracelet (an alarm that will sound if the resident gets close to a door with the sensor) in place. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to place a resident's urinary catheter bag inside of a privacy bag, according to facility policy, to maintain resident dignity. This deficient practice was identified for 1 of 2 residents (Resident #116) reviewed for urinary catheters and was evidenced by the following: During the initial on 12/10/2021 at 11:17 AM, the surveyor observed room [ROOM NUMBER] with the door closed and a sign posted on the outside of the doorway indicating Resident #86 was on contact precautions. On interview the Unit Manager stated, He/she had a suprapubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow) placed recently. [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to implement infection control measures for the handling and storage of respiratory equipment by leaving a tracheostomy mask exposed to the environment and having a corrugated tube on the floor that was connected a resident for two of five residents reviewed for respiratory care, (Resident #112 & Resident #115. Resident #112 and Resident #115 both have tracheostomies (a hole that surgeons make through the front of the neck and into the windpipe for a person to breathe). The deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined the facility failed to a.) to ensure visitors and staff members wore the appropriate personal protective equipment (barriers, such as gowns, face shields, and gloves worn to protect the eyes, mouth, and skin from infectious disease) in a resident's room, b.) ensure appropriate hand hygiene was followed by visitors and staff members, and c.) ensure a urinary drainage bag was not in contact with the floor to prevent the possibility of disease transmission. This deficient practice was identified for 1 out of 4 residents reviewed for the infection control task, (Resident #72) and 1 of 2 residents reviewed for indwelling urinary catheters (Resident #429). The deficient practice was evidenced by the following: [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman for 3 of 3 residents reviewed for hospitalization, Resident # 127, Resident # 129, and Resident #97. This deficient practice was evidenced by the following: On 12/10/21 at 11:27 AM, the surveyor performed a record review of Resident #127. A review of the progress note dated 11/10/2021, indicated that Resident #127 was transferred to the hospital for labored breathing. There was no documented evidence that the Ombudsman was notified of the resident's transfer to the hospital. On 12/21/2021 at 9:25 AM, the surveyor performed a closed record review of Resident #129. A review of the Progress Notes dated 11/3/2021, indicated that Resident #129 was transferred to the hospital for a change in mental status. [...]

Inspectors wroteBased on interview and review of other facility documentation, it was determined that the facility failed to issue the required beneficiary notices for 2 of 3 residents reviewed for Beneficiary Protection Notification (Resident # 93 and Resident # 123. This deficient practice was evidenced by the following: On 12/20/21 at 1:06 PM, the surveyor reviewed the SNF Beneficiary Protection Notification Review (SNFBPNR) completed by the facility for Resident #93. The SNFBPNR indicated that Resident #93's last covered Medicare day was 6/29/21 and Resident #93 remained in the building. The SNFBPNR further revealed that a Notice of Medicare Non-Coverage-Form CMS 10123 (NOMNC) was not provided to Resident #93. The section of the SNFBPNR #2 indicated the NOMNC was not given as Resident #93 still had Medicare A time available. [...]