01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-05-16 | 10 | 2025-05-16 | 10 |
| Cycle 2 | 2024-01-05 | 12 | 2024-01-05 | 0 |
| Cycle 3 | 2021-10-21 | 4 | 2021-10-21 | 1 |
CMS CCN 3153162026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Complete Care At Brakeley Park
290 Red School Lane · Phillipsburg, NJ 08865 · Warren County
Certified beds120CMS provider file
Recent citation rows37current CMS citation release
Penalty rows2current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
37 rows in the current release
2 rows carry G–L scope/severity codes; 1 carry J–L. 5 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-05-16 · HEALTHF0552Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Correction field: Deficient, Provider has date of correction · 2025-06-122025-05-16 · HEALTHF0558Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Correction field: Deficient, Provider has date of correction · 2025-06-122025-05-16 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2025-06-122025-05-16 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2025-06-122025-05-16 · HEALTHF0755Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2025-06-122025-05-16 · HEALTHF0756Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Correction field: Deficient, Provider has date of correction · 2025-06-122025-05-16 · HEALTHF0804Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Correction field: Deficient, Provider has date of correction · 2025-06-122025-05-16 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-06-122025-05-16 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-06-122025-05-16 · HEALTHF0919Severity E · pattern; potential for more than minimal harm
Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Correction field: Deficient, Provider has date of correction · 2025-06-122025-05-16 · FIREK0225Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Correction field: Deficient, Provider has date of correction · 2025-06-082025-05-16 · FIREK0321Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-06-122025-05-16 · FIREK0341Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Install a fire alarm system that can be heard throughout the facility.
Correction field: Deficient, Provider has date of correction · 2025-07-082025-05-16 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2025-06-122025-05-16 · FIREK0363Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2025-07-082025-05-16 · FIREK0374Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Correction field: Deficient, Provider has date of correction · 2025-06-122025-05-16 · FIREK0761Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Correction field: Deficient, Provider has date of correction · 2025-06-122025-05-16 · FIREK0911Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Meet requirements for the installation and maintenance of electrical systems.
Correction field: Deficient, Provider has date of correction · 2025-06-122025-05-16 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2025-07-082025-05-16 · FIREK0923Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
Correction field: Deficient, Provider has date of correction · 2025-06-122024-09-25 · HEALTHF0810Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Correction field: Deficient, Provider has date of correction · 2024-10-18 · complaint2024-08-30 · HEALTHF0658Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2024-09-06 · complaint2024-01-05 · HEALTHF0557Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Correction field: Deficient, Provider has date of correction · 2024-01-232024-01-05 · HEALTHF0565Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to organize and participate in resident/family groups in the facility.
Correction field: Deficient, Provider has date of correction · 2024-01-2303 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-01-05 | Fine | $47,746 | 0 |
| 2023-10-10 | Fine | $7,901 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- PC NJ1 OPCOS LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 07/01/2021
- PC WTA OPCO HOLDCO LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 07/01/2021
- SMS 2021 TRUSTOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 07/01/2021
- STEIN, SHALOMIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 07/01/2021
- WELLTOWER INCOrganization · 5% OR GREATER SECURITY INTERESTNOT APPLICABLE · since 07/01/2021
- GOMES, ANAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 07/01/2021
- SAHAR, ETAYIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 03/28/2023
- STEIN, SHALOMIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 07/01/2021
- STEIN, SHALOMIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/01/2021
- CARDUCCI, DONNAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2021
- GOMES, ANAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2021
- PETOCZ, COURTNEYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/16/2025
- SAHAR, ETAYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 03/28/2023
- SCHWARTZ, HERSHELIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2021
- STEIN, SHALOMIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 07/01/2021
- AURORA GUARDIAN HOLDCO II CO-BORROWER, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/01/2021
- AURORA GUARDIAN HOLDCO II MEZZ BORROWER, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/01/2021
- AURORA GUARDIAN HOLDCO II, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/01/2021
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.29per resident day
RN hours0.55per resident day
Weekend nurse hours2.91per resident day
Staff turnover41.3%CMS reported field
06 / LOCAL RECORDS
Open the Phillipsburg ledger →