Cycle 1
Health 2025-05-16 · Fire 2025-05-16
10 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Phillipsburg, NJ
Complete Care At Brakeley Park LLC
2-star overall rating with 2-star inspections with $55,647 in total fines with 10 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
290 Red School Lane, Phillipsburg, NJ
(908) 859-2800
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
115
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1992-09-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.54
Registered nurse staffing
LPN hours / resident day
1.04
Licensed practical nurse staffing
Aide hours / resident day
1.80
Nurse aide staffing
Weekend hours
2.89
Weekend nurse staffing
RN turnover
38%
Annual RN turnover
Total nurse turnover
35%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.1
About the same
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
93.0%
5 pts better
|
93.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.2%
2.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.7% |
2.4%
2.3 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
11.4%
11.4 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.1% |
4.6%
0.5 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 36.7% |
19.0%
17.7 pts worse
|
19.6%
17.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 27.1% |
13.5%
13.6 pts worse
|
16.7%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.7% |
9.8%
1.9 pts worse
|
16.3%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.0% |
9.7%
1.3 pts worse
|
14.9%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.4% |
15.9%
11.5 pts worse
|
19.8%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
6.0%
3.3 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.1% |
78.7%
9.4 pts better
|
81.7%
6.4 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.1% |
8.2%
7.9 pts worse
|
12.0%
4.1 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.6% |
1.2%
1.4 pts worse
|
1.6%
1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.0% |
80.1%
10.9 pts better
|
79.7%
11.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.1% |
25.4%
2.3 pts better
|
23.9%
0.8 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-05 · Fire 2024-01-05
12 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-10-21 · Fire 2021-10-21
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-16
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-06-08
F · Potential for more than minimal harm
2025-05-16
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-06-12
F · Potential for more than minimal harm
2025-05-16
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-07-08
F · Potential for more than minimal harm
2025-05-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-12
F · Potential for more than minimal harm
2025-05-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-07-08
F · Potential for more than minimal harm
2025-05-16
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-06-12
F · Potential for more than minimal harm
2025-05-16
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-06-12
F · Potential for more than minimal harm
2025-05-16
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-06-12
F · Potential for more than minimal harm
2025-05-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-08
F · Potential for more than minimal harm
2025-05-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-06-12
D · Potential for more than minimal harm
2021-10-21
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2021-11-05
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-16
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-06-12
F · Potential for more than minimal harm
2025-05-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-12
E · Potential for more than minimal harm
2025-05-16
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-06-12
E · Potential for more than minimal harm
2025-05-16
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-16
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-16
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-16
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-12
D · Potential for more than minimal harm
2024-09-25
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-08-30
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-09-06
J · Immediate jeopardy
2024-01-05
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-01-23
E · Potential for more than minimal harm
2024-01-05
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-01-23
E · Potential for more than minimal harm
2024-01-05
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-01-23
E · Potential for more than minimal harm
2024-01-05
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2024-01-23
E · Potential for more than minimal harm
2024-01-05
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-01-23
D · Potential for more than minimal harm
2024-01-05
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-01-23
D · Potential for more than minimal harm
2024-01-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-01-23
D · Potential for more than minimal harm
2024-01-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-01-23
D · Potential for more than minimal harm
2024-01-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-23
D · Potential for more than minimal harm
2024-01-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-23
G · Actual harm
2023-10-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-11
D · Potential for more than minimal harm
2023-06-01
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-07-14
E · Potential for more than minimal harm
2021-10-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-11-17
E · Potential for more than minimal harm
2021-10-21
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-11-17
D · Potential for more than minimal harm
2021-10-21
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-11-10
Penalties and ownership
What sits behind the stars
$47,746
2024-01-05
Fine
Fine · fine $47,746
Fine
$7,901
2023-10-10
Fine
Fine · fine $7,901
Fine
Ownership
Pc Nj1 Opcos LLC
5% Or Greater Direct Ownership Interest · Organization
Carducci, Donna
Operational/Managerial Control · Individual
Gomes, Ana
Operational/Managerial Control · Individual
Pc Wta Opco Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Peace Capital Holdings LLC (De)
5% Or Greater Indirect Ownership Interest · Organization
Petocz, Courtney
Operational/Managerial Control · Individual
Sahar, Etay
Operational/Managerial Control · Individual
Schwartz, Hershel
Operational/Managerial Control · Individual
Sms 2021 Trust
5% Or Greater Indirect Ownership Interest · Organization
Stein, Shalom
Corporate Officer · Individual
Welltower Inc
5% Or Greater Security Interest · Organization
Nearby options
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3-star overall rating with 2-star inspections with 7 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#2
Complete Care At Phillipsburg, LLC
Phillipsburg, NJ
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Gardens At Easton, The
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4-star overall rating with 4-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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