Complete Care at Phillipsburg, LLC

• Star rating

  The CMS overall star rating changed from 3 of 5 to 5 of 5.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 5 of 5.

• Star rating

  The CMS overall star rating changed from 4 of 5 to 3 of 5.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 1 of 5.

CMS lists this as a standard inspection.

• Citation F0584. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

  CMS lists it as corrected on August 5, 2026.

• Citation F0657. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS lists it as corrected on August 5, 2026.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on August 5, 2026.

  CMS has cited this home for F0880 3 times since 2023.

• Citation F0677. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on August 5, 2026.

• Citation F0725. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  CMS lists it as corrected on August 5, 2026.

• Citation F0756. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  CMS lists it as corrected on August 5, 2026.

• Citation F0757. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident’s drug regimen must be free from unnecessary drugs.

  CMS lists it as corrected on August 5, 2026.

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CMS lists this as a standard inspection.

• Citation E0004. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Develop and maintain an Emergency Preparedness Program (EP).

  CMS lists it as corrected on July 30, 2026.

• Citation E0009. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Include a process for Emergency Preparedness collaboration.

  CMS lists it as corrected on August 7, 2026.

• Citation E0030. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: List the names and contact information of those in the facility.

  CMS lists it as corrected on August 7, 2026.

• Citation K0222. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

  CMS lists it as corrected on August 7, 2026.

• Citation K0353. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on August 14, 2026.

• Citation K0363. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on August 7, 2026.

• Citation K0374. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Install smoke barrier doors that can resist smoke for at least 20 minutes.

  CMS lists it as corrected on August 7, 2026.

• Citation K0901. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.

  CMS lists it as corrected on August 13, 2026.

• Citation K0161. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Use approved construction type or materials.

  CMS lists it as corrected on August 7, 2026.

• Citation K0342. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

  CMS lists it as corrected on August 7, 2026.

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• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS overall star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 1 of 5.

CMS lists this as a standard inspection.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on March 31, 2025.

  CMS has cited this home for F0812 2 times since 2023.

• Citation F0645. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: PASARR screening for Mental disorders or Intellectual Disabilities

  CMS lists it as corrected on March 31, 2025.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on March 31, 2025.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on March 31, 2025.

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CMS lists this as a standard inspection.

• Citation K0311. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have an enclosure around a vertical opening shaft.

  CMS lists it as corrected on April 16, 2025.

• Citation K0341. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Install a fire alarm system that can be heard throughout the facility.

  CMS lists it as corrected on March 17, 2025.

• Citation K0355. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Properly select, install, inspect, or maintain portable fire extinguishes.

  CMS lists it as corrected on March 17, 2025.

• Citation K0761. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: To conduct inspection, testing and maintenance of fire doors by qualified individuals.

  CMS lists it as corrected on April 30, 2025.

• Citation K0914. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

  CMS lists it as corrected on March 31, 2025.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on April 30, 2025.

  CMS has cited this home for K0918 2 times since 2023.

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• Star rating

  The CMS overall star rating changed from 5 of 5 to 4 of 5.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 5 of 5 to 3 of 5.

• Star rating

  The CMS overall star rating changed from 4 of 5 to 5 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 5 of 5.

• Star rating

  The CMS overall star rating changed from 5 of 5 to 4 of 5.

• Star rating

  The CMS quality measures star rating changed from 5 of 5 to 4 of 5.

CMS lists this as a standard inspection.

• Citation F0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on February 8, 2023.

• Citation F0812. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on February 8, 2023.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on January 31, 2023.

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CMS lists this as a standard inspection.

• Citation K0211. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Keep aisles, corridors, and exits free of obstruction in case of emergency.

  CMS lists it as corrected on February 1, 2023.

• Citation K0291. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Install emergency lighting that can last at least 1 1/2 hours.

  CMS lists it as corrected on February 8, 2023.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on January 26, 2023.

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