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COMPLETE CARE AT BRAKELEY PARK LLC

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COMPLETE CARE AT BRAKELEY PARK LLC is a for profit - limited liability company facility in PHILLIPSBURG, NJ with 120 certified beds and a 2-star overall CMS rating. The facility has 27 deficiency records on file. Total penalties: $56K.

290 RED SCHOOL LANE, PHILLIPSBURG, NJ 08865

Phone: 9088592800

Overall Rating

2/5

Health Inspection

2/5

Staffing

3/5

Quality Measures

4/5

Long-Stay Quality

5/5

Facility Information

Provider Number
315316
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
Beds
120
Residents
115
In Hospital
No
County
Warren
Last Inspection
May 16, 2025

Staffing Data

RN Hours
0.54 (nat'l avg: 0.68)
LPN Hours
1.04
CNA Hours
1.80
Total Nursing Hours
3.38 (nat'l avg: 3.89)
PT Hours
0.04
Nursing Turnover
35.3%
RN Turnover
37.5%

What the CMS Record Reveals About COMPLETE CARE AT BRAKELEY PARK LLC

COMPLETE CARE AT BRAKELEY PARK LLC operates 120 certified beds in PHILLIPSBURG, NJ with approximately 115 residents currently in care, and carries a CMS overall rating of 2 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (2★), staffing levels (3★), and quality measures (4★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.

The inspection file contains 27 deficiency records from recent surveys, of which 2 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 2 penalties totaling $56K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.38 total nursing hours per resident day (national average 3.89), with RN coverage at 0.54 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.

Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, COMPLETE CARE AT BRAKELEY PARK LLC falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 35.3%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.

Deficiency History (27 most recent)

E — Pattern - Minimal harm May 16, 2025 Tag: 0919

Make sure that a working call system is available in each resident's bathroom and bathing area.

Category: Environmental Deficiencies

Corrected: Jun 12, 2025

D — Isolated - Minimal harm May 16, 2025 Tag: 0880

Provide and implement an infection prevention and control program.

Category: Infection Control Deficiencies

Corrected: Jun 12, 2025

F — Widespread - Minimal harm May 16, 2025 Tag: 0812

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

Category: Nutrition and Dietary Deficiencies

Corrected: Jun 12, 2025

F — Widespread - Minimal harm May 16, 2025 Tag: 0804

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Category: Nutrition and Dietary Deficiencies

Corrected: Jun 12, 2025

D — Isolated - Minimal harm May 16, 2025 Tag: 0756

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

Category: Pharmacy Service Deficiencies

Corrected: Jun 12, 2025

E — Pattern - Minimal harm May 16, 2025 Tag: 0755

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Category: Pharmacy Service Deficiencies

Corrected: Jun 12, 2025

D — Isolated - Minimal harm May 16, 2025 Tag: 0695

Provide safe and appropriate respiratory care for a resident when needed.

Category: Quality of Life and Care Deficiencies

Corrected: Jun 12, 2025

D — Isolated - Minimal harm May 16, 2025 Tag: 0690

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Category: Quality of Life and Care Deficiencies

Corrected: Jun 12, 2025

D — Isolated - Minimal harm May 16, 2025 Tag: 0558

Reasonably accommodate the needs and preferences of each resident.

Category: Resident Rights Deficiencies

Corrected: Jun 12, 2025

D — Isolated - Minimal harm May 16, 2025 Tag: 0552

Ensure that residents are fully informed and understand their health status, care and treatments.

Category: Resident Rights Deficiencies

Corrected: Jun 12, 2025

D — Isolated - Minimal harm Sep 25, 2024 Tag: 0810

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Category: Nutrition and Dietary Deficiencies

Corrected: Oct 18, 2024

E — Pattern - Minimal harm Aug 30, 2024 Tag: 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Sep 6, 2024

D — Isolated - Minimal harm Jan 5, 2024 Tag: 0812

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

Category: Nutrition and Dietary Deficiencies

Corrected: Jan 23, 2024

E — Pattern - Minimal harm Jan 5, 2024 Tag: 0759

Ensure medication error rates are not 5 percent or greater.

Category: Pharmacy Service Deficiencies

Corrected: Jan 23, 2024

E — Pattern - Minimal harm Jan 5, 2024 Tag: 0711

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Category: Nursing and Physician Services Deficiencies

Corrected: Jan 23, 2024

E — Pattern - Minimal harm Jan 5, 2024 Tag: 0698

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Category: Quality of Life and Care Deficiencies

Corrected: Jan 23, 2024

D — Isolated - Minimal harm Jan 5, 2024 Tag: 0695

Provide safe and appropriate respiratory care for a resident when needed.

Category: Quality of Life and Care Deficiencies

Corrected: Jan 23, 2024

J — Isolated - Jeopardy Jan 5, 2024 Tag: 0678

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Category: Quality of Life and Care Deficiencies

Corrected: Jan 23, 2024

D — Isolated - Minimal harm Jan 5, 2024 Tag: 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Jan 23, 2024

D — Isolated - Minimal harm Jan 5, 2024 Tag: 0656

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Jan 23, 2024

E — Pattern - Minimal harm Jan 5, 2024 Tag: 0565

Honor the resident's right to organize and participate in resident/family groups in the facility.

Category: Resident Rights Deficiencies

Corrected: Jan 23, 2024

D — Isolated - Minimal harm Jan 5, 2024 Tag: 0557

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Category: Resident Rights Deficiencies

Corrected: Jan 23, 2024

G — Isolated - Actual harm Oct 10, 2023 Tag: 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Category: Quality of Life and Care Deficiencies

Corrected: Oct 11, 2023

D — Isolated - Minimal harm Jun 1, 2023 Tag: 0908

Keep all essential equipment working safely.

Category: Environmental Deficiencies

Corrected: Jul 14, 2023

D — Isolated - Minimal harm Oct 21, 2021 Tag: 0804

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Category: Nutrition and Dietary Deficiencies

Corrected: Nov 10, 2021

E — Pattern - Minimal harm Oct 21, 2021 Tag: 0692

Provide enough food/fluids to maintain a resident's health.

Category: Quality of Life and Care Deficiencies

Corrected: Nov 17, 2021

E — Pattern - Minimal harm Oct 21, 2021 Tag: 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Nov 17, 2021

Quality Measures

Measure Type Score Used in Rating
Percentage of long-stay residents whose need for help with daily activities has increased Long Stay 11.0% Yes
Percentage of long-stay residents who lose too much weight Long Stay 4.1% No
Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay 0.0% Yes
Percentage of long-stay residents with a urinary tract infection Long Stay 0.0% Yes
Percentage of long-stay residents who have depressive symptoms Long Stay 0.0% No
Percentage of long-stay residents who were physically restrained Long Stay 0.0% No
Percentage of long-stay residents experiencing one or more falls with major injury Long Stay 4.7% Yes
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine Long Stay 98.0% No
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine Short Stay 88.1% No
Percentage of short-stay residents who newly received an antipsychotic medication Short Stay 2.6% Yes
Percentage of long-stay residents whose ability to walk independently worsened Long Stay 11.7% Yes
Percentage of long-stay residents who received an antianxiety or hypnotic medication Long Stay 36.7% No
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine Long Stay 100.0% No
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine Short Stay 91.0% No
Percentage of long-stay residents with pressure ulcers Long Stay 2.7% Yes
Percentage of long-stay residents with new or worsened bowel or bladder incontinence Long Stay 27.4% No
Percentage of long-stay residents who received an antipsychotic medication Long Stay 27.1% Yes

Penalty History 2 penalties totaling $56K

Date Type Amount
Jan 5, 2024 Fine $48K
Oct 10, 2023 Fine $8K

Frequently Asked Questions

What is the overall CMS rating for COMPLETE CARE AT BRAKELEY PARK LLC?
COMPLETE CARE AT BRAKELEY PARK LLC has an overall CMS rating of 2 out of 5 stars. This rating combines health inspection results (2★), staffing levels (3★), and quality measures (4★).
What are the staffing levels at COMPLETE CARE AT BRAKELEY PARK LLC?
COMPLETE CARE AT BRAKELEY PARK LLC reports 3.38 total nursing hours per resident day (national average: 3.89). RN hours are 0.54 per resident day (national average: 0.68). Nursing staff turnover is 35.3%.
How many beds does COMPLETE CARE AT BRAKELEY PARK LLC have?
COMPLETE CARE AT BRAKELEY PARK LLC has 120 certified beds with approximately 115 residents. The facility is located at 290 RED SCHOOL LANE, PHILLIPSBURG, NJ 08865.
Does COMPLETE CARE AT BRAKELEY PARK LLC have any deficiencies on record?
Yes, COMPLETE CARE AT BRAKELEY PARK LLC has 27 deficiencies on record from recent inspections. Of these, 2 are classified as causing actual harm or jeopardy.
Has COMPLETE CARE AT BRAKELEY PARK LLC received any fines or penalties?
Yes, COMPLETE CARE AT BRAKELEY PARK LLC has received 2 penalties totaling $56K.
Who owns COMPLETE CARE AT BRAKELEY PARK LLC?
COMPLETE CARE AT BRAKELEY PARK LLC is classified as "For profit - Limited Liability company" ownership. The facility type is "Medicare and Medicaid".
When was COMPLETE CARE AT BRAKELEY PARK LLC last inspected?
The most recent health inspection for COMPLETE CARE AT BRAKELEY PARK LLC was on May 16, 2025. The facility received a health inspection rating of 2 out of 5 stars.
What quality measures are tracked for COMPLETE CARE AT BRAKELEY PARK LLC?
COMPLETE CARE AT BRAKELEY PARK LLC is evaluated on 17 quality measures, of which 8 are used in the CMS star rating calculation. These include measures for both long-stay and short-stay residents covering areas like infections, falls, pressure ulcers, and medication use.

Data Sources

Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.

Related

Data sourced from official U.S. government datasets. See our methodology for details. Retrieved and formatted by PlainNursing Editorial