Cycle 1
Health 2025-02-24 · Fire 2025-02-24
4 health deficiencies
Top issue: Infection Control (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Phillipsburg, NJ
Complete Care At Phillipsburg, LLC
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
843 Wilbur Avenue, Phillipsburg, NJ
(908) 454-2627
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
56
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1992-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
85 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.41
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.19
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.33
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.15
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
2.91
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.45
CMS adjusted RN staffing hours
Adjusted total hours
3.64
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,695
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.68
Composite VBP score used to determine payment impact.
Payment multiplier
0.9815
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.92
Baseline 18.44% · Performance 19.62% · Measure score 3.92 · Achievement 3.92 · Improvement 0
Healthcare-associated infections
0
Baseline 6.15% · Performance 8.09% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
0.79
Baseline 3.47 hours · Performance 3.30 hours · Measure score 0.79 · Achievement 0.79 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.48% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 92 · Observed rate 14.13% · Lower 95% interval 8.2% |
| Discharge to community | 47.04% |
50.57%
3.5 pts worse
|
No Different than the National Rate · Eligible stays 66 · Observed rate 40.91% · Lower 95% interval 34.8% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 69 · Denominator 69 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 69 |
| Discharge self-care score | 64.29% |
53.69%
10.6 pts better
|
Numerator 27 · Denominator 42 |
| Discharge mobility score | 59.52% |
50.94%
8.6 pts better
|
Numerator 25 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 7.35% |
2.29%
5.1 pts worse
|
Numerator 5 · Denominator 68 · Adjusted rate 7.81% |
| Healthcare-associated infections requiring hospitalization | 8.09% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 11.11% · Lower 95% interval 4.51% |
| Staff COVID-19 vaccination coverage | 6.49% |
8.2%
1.7 pts worse
|
Numerator 5 · Denominator 77 |
| Staff flu vaccination coverage | 92.77% |
42%
50.8 pts better
|
Numerator 77 · Denominator 83 |
| Discharge function score | 64.29% |
56.45%
7.8 pts better
|
Numerator 27 · Denominator 42 |
| Transfer of health information to provider | 96.97% |
95.95%
1 pts better
|
Numerator 32 · Denominator 33 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 20.51% |
25.2%
4.7 pts worse
|
Numerator 8 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.1
0.4 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.9 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.1
0.4 pts worse
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.3% |
93.0%
7.7 pts worse
|
93.4%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 89.8% · Q2 88.4% · Q3 86.0% · Q4 77.6% · 4Q avg 85.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.9% |
97.2%
1.3 pts worse
|
95.5%
0.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
2.4%
0.3 pts worse
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 2.3% · Q3 2.3% · Q4 2.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.7% |
11.4%
0.3 pts worse
|
11.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 12.2% · Q3 17.5% · Q4 6.5% · 4Q avg 11.7% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
4.6%
1.2 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 2.4% · Q3 0.0% · Q4 0.0% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.8% |
19.0%
4.8 pts worse
|
19.6%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 23.3% · Q3 26.2% · Q4 18.8% · 4Q avg 23.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.7% |
13.5%
12.2 pts worse
|
16.7%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 24.0% · Q3 28.6% · Q4 23.5% · 4Q avg 25.7% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.2% |
9.8%
0.6 pts better
|
16.3%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 10.5% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.9% |
9.7%
0.8 pts better
|
14.9%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 5.4% · Q3 8.1% · Q4 6.8% · 4Q avg 8.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.7%
0.2 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.1% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
0.8%
0.3 pts worse
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.8% |
15.9%
12.9 pts worse
|
19.8%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.2% · Q2 31.4% · Q3 19.4% · Q4 29.2% · 4Q avg 28.8% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
6.0%
0.6 pts better
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 8.2% · Q3 4.9% · Q4 2.6% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 59.4% |
78.7%
19.3 pts worse
|
81.7%
22.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 53.7% · Q2 60.4% · Q3 64.9% · Q4 56.5% · 4Q avg 59.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.4% |
8.2%
2.8 pts better
|
12.0%
6.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.4% · Observed 5.1% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.2%
0.7 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 3.2% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.5% |
80.1%
4.6 pts worse
|
79.7%
4.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.7% |
25.4%
1.3 pts worse
|
23.9%
2.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.7% · Observed 27.1% · Expected 24.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-09 · Fire 2023-01-09
3 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2020-10-29 · Fire 2020-10-29
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-24
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-04-16
F · Potential for more than minimal harm
2025-02-24
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-03-17
F · Potential for more than minimal harm
2025-02-24
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-17
F · Potential for more than minimal harm
2025-02-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-02-24
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-03-31
F · Potential for more than minimal harm
2025-02-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-30
F · Potential for more than minimal harm
2023-01-09
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-02-01
F · Potential for more than minimal harm
2023-01-09
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-02-08
F · Potential for more than minimal harm
2023-01-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-26
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-02-24
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 2025-03-31
D · Potential for more than minimal harm
2025-02-24
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-31
D · Potential for more than minimal harm
2023-01-09
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-02-08
D · Potential for more than minimal harm
2023-01-09
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 2023-02-08
D · Potential for more than minimal harm
2023-01-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-31
D · Potential for more than minimal harm
2020-10-29
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2020-11-10
Penalties and ownership
What sits behind the stars
Ownership
Pc Nj1 Opcos LLC
5% Or Greater Direct Ownership Interest · Organization
Pc Wta Opco Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Peace Capital Holdings LLC (De)
5% Or Greater Indirect Ownership Interest · Organization
Schwartz, Hershel
W-2 Managing Employee · Individual
Sms 2021 Trust
5% Or Greater Indirect Ownership Interest · Organization
Stein, Shalom
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Complete Care At Brakeley Park LLC
Phillipsburg, NJ
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
#2
Lopatcong Center
Phillipsburg, NJ
3-star overall rating with 2-star inspections with 7 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#3
Gardens At Easton, The
Easton, PA
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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