Inspection Reports for
Complete Care At Phillipsburg, Llc
843 Wilbur Avenue, Phillipsburg, NJ, 08865
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
4.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
8% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
85% occupied
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Notice
Deficiencies: 0
Date: Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Routine
Census: 51
Deficiencies: 4
Date: Feb 24, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to mental health screenings, respiratory care, food safety, infection prevention, and catheter care at the facility.
Findings
The facility failed to ensure accurate PASARR Level II screenings for one resident, incomplete respiratory assessments before nebulizer treatments for one resident, improper drying and storage of kitchen pans, and failure to keep a catheter bag off the floor for one resident, all posing potential risks to resident health and safety.
Deficiencies (4)
Failed to ensure one resident had accurate PASARR screenings and/or referral for Level II review after a positive Level I screening.
Failed to complete respiratory assessment prior to nebulizer treatment and failed to monitor respiratory condition during treatment for one resident.
Failed to ensure kitchen staff properly air-dried pans prior to storage, increasing risk of foodborne illness.
Failed to ensure catheter bag was kept off the floor for one resident, increasing risk of urinary tract infection.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 49
Residents affected: 1
Total census: 51
Sample size: 23
Sample size: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Director | Interviewed regarding PASARR screening process | |
| Administrator | Interviewed regarding PASARR screening process and corrective actions | |
| LPN1 | Licensed Practical Nurse | Administered nebulizer treatment and confirmed lack of respiratory assessment |
| Regional Clinical Nurse | Added respiratory assessment order to MAR | |
| Infection Preventionist | Interviewed regarding respiratory assessment expectations | |
| Dietary Manager | Dietary Manager | Confirmed wet pans and dirty can opener during kitchen observation |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
Date: Sep 10, 2024
Visit Reason
The inspection was conducted based on complaints NJ 174554 and NJ 176529 to investigate compliance with staffing requirements and other regulatory standards.
Complaint Details
Complaint NJ174554 and NJ176529 were investigated. The facility was found deficient in CNA staffing for residents on 5 of 14 day shifts and deficient in total staff for residents on 9 of 14 overnight shifts. No residents were immediately affected, but all residents had the potential to be affected.
Findings
The facility was found to be substantially compliant overall but failed to maintain the required minimum direct care staff to resident ratios for the day shift as mandated by New Jersey state law, with deficiencies noted in CNA and total staff coverage on multiple day and overnight shifts.
Deficiencies (1)
Failure to maintain the required minimum direct care staff to resident ratios for the day shift as mandated by the State of New Jersey.
Report Facts
Census: 52
Sample size: 5
Deficient CNA staffing day shifts: 5
Deficient total staff overnight shifts: 9
Required CNA staffing: 7
Actual CNA staffing: 3.25
Required total staff overnight: 4
Inspection Report
Annual Inspection
Census: 54
Deficiencies: 9
Date: Mar 3, 2023
Visit Reason
A Federal Comparative Survey was conducted by the Centers for Medicare and Medicaid Services (CMS) at Complete Care at Phillipsburg for federal oversight, monitoring, and to determine compliance with 42 CFR Part 483 requirements for Long Term Care.
Findings
The facility was found not to be in substantial compliance with federal regulations, with deficiencies identified in resident rights to survey results, personal privacy and confidentiality, safe and clean environment, professional standards of care, ADL care, respiratory care, pharmacy services, food safety, and nurse aide training. A post-certification revisit report indicates all cited deficiencies were corrected by 04/30/2023 or 06/01/2023.
Deficiencies (9)
Failure to have Department of Health Recertification survey reports for the three preceding years available for review.
Failure to ensure resident personal privacy and confidentiality of records, including dignified storage of resident information.
Failure to maintain a clean, orderly, functional, and sanitary environment in multiple resident rooms and facility areas.
Licensed Practical Nurses conducting and documenting initial nursing comprehensive admission assessments without Registered Nurse concurrence for 2 residents.
Failure to provide necessary ADL care including hygiene and grooming for dependent residents.
Failure to ensure proper signage was posted when respiratory equipment was in use for one resident.
Failure to consistently maintain an accounting of controlled substances in the automated medication dispensing system.
Failure to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner in the kitchen and food storage areas.
Failure to maintain an effective tracking system and ensure Certified Nursing Assistants received twelve hours of mandatory in-service training including dementia management and resident abuse prevention.
Report Facts
Census: 54
Sample Size: 43
In-service training hours: 12
Missing controlled substance counts: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in findings related to failure to provide necessary ADL care and incomplete in-service training |
| Unit Manager | Licensed Practical Nurse | Interviewed regarding nursing assessments and environmental issues |
| Facility Director of Nursing | Director of Nursing | Interviewed regarding nursing assessments and controlled substance counts |
| Facility Educator | Facility Educator | Interviewed regarding CNA in-service training and education tracking |
| Food Service Director | Food Service Director | Interviewed regarding kitchen sanitation and food safety deficiencies |
| Administrator | Acting Administrator | Interviewed regarding facility compliance and staff training |
Inspection Report
Routine
Deficiencies: 3
Date: Jan 9, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to medication labeling and storage, food safety and sanitation, and infection prevention and control practices at the nursing home facility.
Findings
The facility was found deficient in properly dating and storing medications, maintaining kitchen cleanliness and food safety standards, and cleaning and disinfecting resident shower chairs. These deficiencies posed minimal harm or potential for actual harm to residents.
Deficiencies (3)
Failure to date medication when opened and stored for continued use in medication carts and refrigerator.
Failure to store potentially hazardous foods properly and maintain kitchen environment and equipment in a sanitary manner.
Failure to clean and disinfect three shower chairs in the shower room, resulting in soiled equipment.
Report Facts
Medication carts inspected: 3
Medication refrigerator inspected: 1
Stovetop burners soiled: 4
Shower chairs observed: 3
Residents interviewed: 5
Residents reporting shower chair concerns: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Confirmed dates on medication vials and acknowledged expired medications. |
| Unit Manager/LPN | UM/LPN | Confirmed undated vial in medication refrigerator. |
| Director of Nursing | DON | Acknowledged concerns about undated or expired medications and soiled shower chairs. |
| Food Service Manager | FSM | Observed kitchen deficiencies including soiled equipment and expired food. |
| Regional Food Service Director | RFSD | Present during kitchen inspection. |
| Housekeeping Director | Stated shower chairs had never been cleaned by housekeeping. |
Inspection Report
Routine
Census: 52
Capacity: 60
Deficiencies: 6
Date: Jan 9, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
The facility was found to have deficiencies related to medication labeling and storage, food safety and sanitation, infection prevention and control, and cleaning and disinfecting of resident equipment. Additionally, a Life Safety Code Survey found noncompliance with fire door inspections and emergency lighting.
Deficiencies (6)
Failed to date medication when opened and stored for continued use in medication carts and refrigerator.
Failed to maintain kitchen environment and equipment in a sanitary manner to prevent contamination and food borne illness.
Failed to maintain an infection prevention and control program including cleaning and disinfecting shower chairs.
Failed to maintain fire doors inspected annually as required by NFPA 101 Life Safety Code.
Failed to ensure emergency lighting was provided at the emergency generator transfer switch.
Failed to complete a three-year load bank test on the emergency generator.
Report Facts
Census: 52
Total Capacity: 60
Sample Size: 15
Deficiencies cited: 6
Compliance date: 2023
Inspection Report
Abbreviated Survey
Census: 41
Deficiencies: 0
Date: Feb 4, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 11
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 0
Date: Dec 16, 2020
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00140923 and NJ00132440.
Complaint Details
Complaint #: NJ00140923 and NJ00132440. The facility was found compliant based on this complaint survey.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Report Facts
Sample Size: 3
Inspection Report
Deficiencies: 1
Date: Oct 29, 2020
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care plan requirements following a fall incident involving Resident #35, specifically to assess whether the care plan was revised to include monitoring of injuries sustained during the fall.
Findings
The facility failed to revise the comprehensive care plan to include monitoring of injuries sustained during a fall for Resident #35. Despite documentation of the fall and injuries in progress notes and event summaries, the care plan was not updated accordingly, and the Director of Nursing agreed there was no update on the fall care plan regarding the actual fall.
Deficiencies (1)
Failure to revise a comprehensive care plan to include monitoring of injuries sustained during a fall for Resident #35.
Report Facts
Residents Affected: 3
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