Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Phillipsburg, Llc during CMS and state inspections, most recent first.
A facility failed to maintain a safe, clean, comfortable, and homelike environment. During tour, the surveyor observed multiple resident rooms and common areas with stained and buckled ceiling tiles, damaged floor tiles, dirty window tracks, wall damage, and broken ceiling tiles in the kitchen, hallway, dining room, and bathroom areas. The DM stated he had not been made aware of the concerns and was still becoming familiar with the TELS system, while the LNHA acknowledged awareness of the environmental concerns.
The facility failed to keep care plans current for three residents. One resident with stroke-related deficits and cognitive impairment had a care plan that still encouraged call bell use even though staff said the resident could not use it. Another resident’s care plan listed anxiety but did not include a family-placed sign to leave the TV on at night. A third resident’s care plan addressed incontinence but did not reflect urinary retention or an active order for Tamsulosin.
Infection control standards were not maintained when an LPN observed visibly soiled TF machines for three residents with enteral feedings, including machines with yellowish and brown-yellowish substances present. During wound care for a resident with a sacral wound and multiple wounds, the LPN used scissors that were not disinfected, handled a sterile calcium alginate dressing with gloved hands, and did not disinfect the OBT after the treatment. The resident had significant cognitive impairment and diagnoses including gangrene, PVD, and vascular dementia.
Delayed Incontinence Care for Two Dependent Residents: Two dependent residents were observed with briefs saturated with urine during a nursing unit tour. One resident had severe cognitive impairment, was frequently incontinent of bowel and bladder, and had a care plan calling for toileting and brief changes when incontinent. The other resident had moderate cognitive impairment, was always incontinent of bladder, frequently incontinent of bowel, and required total assistance with ADLs. CNA staff and the DON confirmed incontinence care should be provided every 2 hours.
The facility failed to meet required CNA staffing ratios and failed to ensure timely incontinence care for two dependent residents. Surveyors found multiple shifts with fewer CNAs than required for the resident census, and observed two residents with briefs saturated with urine while assigned CNAs confirmed the briefs were saturated. The staffing coordinator was unsure of the night-shift ratio, and the DON confirmed that incontinence care should be provided every 2 hours.
A CP failed to identify and clarify a medication route discrepancy during the monthly MRR for a resident with a g-tube, NPO status, and moderate cognitive impairment. The resident had Risperdal orders written for PO administration even though nursing staff stated all meds were given via g-tube, and the CP acknowledged the discrepancy should have been caught and corrected.
PRN Acetaminophen Order Lacked Specific Indication: A resident with DM2, hypothyroidism, hyperlipidemia, and severe cognitive impairment had an acetaminophen PRN order written for multiple reasons, including pain, headaches, and fever, without a specific condition or temperature parameter. The DON acknowledged that PRN orders should be specific and not list several reasons, and the facility policy required PRN orders to specify the condition for administration.
Unsafe and Unhomelike Environmental Conditions
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment in resident rooms and common areas. During the initial tour, the surveyor observed multiple environmental deficiencies on the resident unit, including stained and buckled ceiling tiles in several resident rooms and bathrooms, damaged floor tiles, dirty window tracks, damaged ceiling tile frames, multiple areas of wall damage, and stained or broken ceiling tiles in the hallway, dining room, kitchen, and outside the first-floor bathroom. The facility provided its policy titled, Safe and Homelike Environment, which states that residents will be provided a safe, clean, comfortable and homelike environment. During the tour with the DM, he stated he had not been made aware of the concerns and said his expectation was that staff would inform him verbally; he also stated he was still becoming familiar with the TELS system and did not use it regularly. The LNHA later stated the facility was aware of the environmental concerns.
Care Plans Not Updated to Match Resident Needs
Penalty
Summary
The facility failed to update and revise the comprehensive care plan for 3 of 15 residents reviewed. The report identified that the care plans were not kept consistent with resident assessments, current conditions, and physician orders, despite the facility policy stating that the comprehensive care plan will be reviewed and revised after each comprehensive and quarterly MDS assessment. For one resident with diagnoses including hypertension and hemiplegia/hemiparesis following cerebral infarction, the quarterly MDS showed moderate cognitive impairment, absence of spoken words, and total dependence on caregivers. Staff interviews indicated the resident was unlikely to be able to use the call bell, yet the care plan still contained an intervention stating the call light was within reach and to encourage use. An updated care plan later reflected that the resident was unable to use the call bell. For another resident with diagnoses including type 2 diabetes, hypothyroidism, and hyperlipidemia, a handwritten sign was observed stating to leave the TV on at night due to anxiety. Staff stated a family member had placed the sign and often made requests to staff. The resident’s care plan listed anxiety disorder, but it did not include the TV-on-at-night request, the sign placement, or that the family had placed the sign. For a third resident with hypertension, diabetes, and urinary retention, the MDS showed occasional incontinence and the resident had an active order for Tamsulosin for urinary retention, but the care plan still focused on incontinence and did not reflect urinary retention or treatment with medication.
Infection Control Lapses With Tube Feeding Equipment and Wound Care
Penalty
Summary
The facility failed to maintain cleanliness of resident care equipment for three residents receiving enteral feedings. On observation, the surveyor found droplet-shaped yellowish substances on the enteral feeding machines for two residents and droplet-shaped brown-yellowish substances on another resident’s enteral feeding machine. The residents had diagnoses that included gastrostomy, dysphagia, adult failure to thrive, diabetes mellitus, hypertension, and gastro-esophageal reflux disease, and two of the residents were assessed as having moderate cognitive impairment while one resident could not complete a BIMS due to inability to be understood. The medical record review confirmed that each of the three residents had physician orders for continuous tube feeding via g-tube or pump. The facility policy stated that reusable resident-care equipment is a source of indirect transmission of pathogens and that direct care staff are responsible for cleaning single-resident equipment when visibly soiled. During interview, an LPN stated that the TF machines are to be cleaned by housekeeping and nursing staff and acknowledged that two of the observed TF machines needed to be cleaned and sanitized. The facility also failed to maintain infection control standards during wound care for one resident with a sacral wound and multiple wounds on admission, including frostbite and a sacral Kennedy ulcer. During the observed wound treatment, the LPN disinfected the overbed table and used a clean barrier, but after removing the soiled dressing and changing gloves, the LPN cut the sterile calcium alginate dressing with scissors that had not been disinfected and touched the entire sterile dressing with gloved hands before applying it to the wound bed. After the treatment was completed, the LPN did not disinfect the overbed table. The LPN acknowledged that the scissors should have been disinfected before use, that only the edges of the sterile dressing should have been touched, and that the overbed table should have been disinfected after the treatment.
Delayed Incontinence Care for Two Dependent Residents
Penalty
Summary
The facility failed to ensure timely incontinence care for two dependent residents observed on the nursing unit. During an incontinence care tour, Resident #25 was found in bed with a brief saturated with urine, and CNA #1 confirmed the brief was saturated and stated that incontinence care should be done every 2 hours. Resident #52 was also observed in bed with a brief saturated with urine, and CNA #2 confirmed the brief was saturated. Record review showed Resident #25 had diagnoses including chronic kidney disease and diabetes mellitus, a BIMS score of 5 indicating severe cognitive impairment, and was frequently incontinent of bowel and bladder and dependent on staff for toileting. The care plan identified risk for impaired skin integrity related to incontinence and directed staff to offer toileting before meals, at bedtime, and when needed, and to perform brief changes and perineal care when incontinent. Resident #52 had diagnoses including a history of urinary tract infections and diabetes mellitus, was assessed as moderately cognitively impaired, was always incontinent of bladder, frequently incontinent of bowel, and dependent on staff for toileting; the care plan stated the resident required total assistance with ADL care. The LPN/Unit Manager and DON confirmed that incontinence care should be provided every 2 hours.
Staffing Shortages and Missed Incontinence Care
Penalty
Summary
The facility failed to maintain the required minimum direct care staffing ratios and failed to ensure sufficient and competent staff were available to provide incontinence care to dependent residents. A review of the New Jersey Department of Health staffing report for the two-week period before the standard survey showed the facility was short on CNA staffing on 8 of 14 day shifts and short on total staff on 1 of 14 overnight shifts. Examples included day shifts with only 3, 4, 5, or 6 CNAs for 56 to 59 residents when at least 7 CNAs were required, and one overnight shift with 3 total staff for 56 residents when at least 4 were required. During an incontinence care tour, the surveyor observed two residents in bed with briefs saturated with urine. One CNA confirmed that the brief was saturated and stated that incontinence care should be done every 2 hours. Another CNA also confirmed that the second resident’s brief was saturated. The surveyor later reviewed the 11:00 PM to 7:00 AM assignment sheet, which showed the unit had a census of 58 residents with 3 assigned CNAs, and that the two CNAs assigned to the residents each had 15 residents on their assignment. The staffing coordinator stated she was aware of the CNA staffing ratios for the day and evening shifts but was not sure about the night shift ratio. The DON confirmed that CNAs should provide incontinence care every 2 hours on all shifts. Facility policies reviewed by the surveyor stated that residents unable to carry out activities of daily living would receive necessary services to maintain hygiene and that the facility would provide qualified and appropriate staffing levels to meet resident needs and state and federal staffing requirements.
Pharmacist Failed to Clarify Oral Medication Orders for NPO Resident With G-Tube
Penalty
Summary
The Consultant Pharmacist failed to clarify a medication route discrepancy during the monthly medication regimen review for a resident with a gastrostomy tube, type 2 diabetes mellitus, gastro-esophageal reflux disease, and moderate cognitive impairment. The resident’s quarterly MDS indicated enteral feeding, and the admission record and nursing observations showed the resident received medications through the g-tube and was NPO. However, the June physician order summary included Risperdal oral tablet orders written to be given by mouth, including one at bedtime and one daily for bipolar disorder. The surveyor reviewed the resident’s record and found a medication regimen review note dated 5/24/26 with no recommendations noted. A nurse stated the resident takes all medications through the g-tube and that the oral Risperdal orders should have been noted and corrected. The CP stated he reviews resident charts for medication discrepancies and acknowledged that the orders written by mouth despite NPO should have been caught and corrected. Facility policy required the pharmacist to report irregularities to the attending physician, medical director, and DON, and for those reports to be acted upon.
PRN Acetaminophen Order Lacked Specific Indication
Penalty
Summary
The facility failed to ensure that a resident did not receive an unnecessary medication by not correctly documenting a diagnosis, indication, or reason for use for one of five residents reviewed for unnecessary medication. Resident #12 was admitted with diagnoses including Type 2 diabetes with hyperglycemia, hypothyroidism, and hyperlipidemia, and the cMDS dated 4/2/26 showed a BIMS score of 7 out of 15, indicating severe cognitive impairment. Review of the resident’s EMR and order summary showed an acetaminophen order for 325 mg, 2 tablets by mouth every 6 hours as needed for mild pain, moderate pain, severe pain, headaches, or fever. During interview, the DON stated that as-needed medication orders should be specific and not list several different reasons, and agreed that the acetaminophen order should have been separated into different PRN orders with a specific temperature to identify fever. The DON stated the order would be changed to correctly reflect when to administer. The facility policy titled Medication Orders stated that PRN orders should specify the condition for which they are being administered.
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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.
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Nursing homes near Phillipsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Brakeley Park | 1.6 mi | ★★★★★ | 0 | 0 |
| Lopatcong Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Gardens At Easton, The | 2.1 mi | ★★★★★ | 1 | 0 |
| Gardens For Memory Care At Easton, The | 2.1 mi | ★★★★★ | 8 | 0 |
| New Eastwood Healthcare And Rehabilitation Center | 3.7 mi | ★★★★★ | 0 | 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 October 2026) and official state health department websites.