COMPLETE CARE AT BURLINGTON WOODS, LLC Inspection Report, Violations & Safety Grade (BURLINGTON, New Jersey)

115 SUNSET ROAD, BURLINGTON, New Jersey 08016

Phone: 6093873620

CMS Overall:4/5

Overview & Bed Count

Certified Beds

215

Avg Residents/Day

181.8

Ownership

For profit - Limited Liability company

Provider Type

Medicare and Medicaid

County

Burlington

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

CMS Star Ratings

Overall4/5

Health3/5

Staffing3/5

Quality5/5

Nurse Staffing Check

Metric	This Facility	New Jersey Avg	Difference
RN Hours per Resident per Day	0.48	0.70	-0.22
Total Nurse Hours per Resident per Day	3.64	3.90	-0.26
CMS Staffing Rating	3/5	3.2/5	-
Nursing Staff Turnover	34.3%	39.3%	-

Health Citation History

23 health citations on record

Date	Category	Description	Severity
2026-01-27	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	D – Moderate Harm Potential
2025-06-04	Resident Assessment and Care Planning Deficiencies	Ensure services provided by the nursing facility meet professional standards of quality.	D – Moderate Harm Potential
2025-06-04	Quality of Life and Care Deficiencies	Provide safe and appropriate respiratory care for a resident when needed.	D – Moderate Harm Potential
2025-06-04	Nursing and Physician Services Deficiencies	Post nurse staffing information every day.	D – Moderate Harm Potential
2023-12-13	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	G – Actual Harm
2023-12-13	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	F – Moderate Harm Potential
2023-12-13	Administration Deficiencies	Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.	F – Moderate Harm Potential
2023-12-13	Resident Rights Deficiencies	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.	E – Moderate Harm Potential
2023-12-13	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	E – Moderate Harm Potential
2023-12-13	Quality of Life and Care Deficiencies	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	E – Moderate Harm Potential
2023-12-13	Nursing and Physician Services Deficiencies	Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.	E – Moderate Harm Potential
2023-12-13	Administration Deficiencies	Have a plan that describes the process for conducting QAPI and QAA activities.	E – Moderate Harm Potential
2023-12-13	Environmental Deficiencies	Put firmly secured handrails on each side of hallways.	E – Moderate Harm Potential
2023-12-13	Nutrition and Dietary Deficiencies	Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.	D – Moderate Harm Potential
2023-12-13	Administration Deficiencies	Have the Quality Assessment and Assurance group have the required members and meet at least quarterly	D – Moderate Harm Potential
2023-12-13	Resident Rights Deficiencies	Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.	D – Moderate Harm Potential
2023-12-13	Resident Assessment and Care Planning Deficiencies	Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.	D – Moderate Harm Potential
2023-12-13	Quality of Life and Care Deficiencies	Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.	D – Moderate Harm Potential
2021-07-29	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	F – Moderate Harm Potential
2021-07-29	Resident Rights Deficiencies	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.	D – Moderate Harm Potential
2021-07-29	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	D – Moderate Harm Potential
2021-07-29	Quality of Life and Care Deficiencies	Provide enough food/fluids to maintain a resident's health.	D – Moderate Harm Potential
2021-07-29	Pharmacy Service Deficiencies	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	D – Moderate Harm Potential

Fire Safety Citation History

14 fire safety citations on record

Date	Category	Description	Severity
2025-06-04	Egress Deficiencies	Install proper backup exit lighting.	F – Moderate Harm Potential
2025-06-04	Smoke Deficiencies	Provide properly protected cooking facilities.	F – Moderate Harm Potential
2025-06-04	Smoke Deficiencies	Install corridor and hallway doors that block smoke.	F – Moderate Harm Potential
2025-06-04	Smoke Deficiencies	Install smoke barrier doors that can resist smoke for at least 20 minutes.	F – Moderate Harm Potential
2025-06-04	Services Deficiencies	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	F – Moderate Harm Potential
2023-12-13	Smoke Deficiencies	Have an enclosure around a vertical opening shaft.	F – Moderate Harm Potential
2023-12-13	Gas, Vacuum, and Electrical Systems Deficiencies	Meet requirements for the installation and maintenance of electrical systems.	F – Moderate Harm Potential
2023-12-13	Gas, Vacuum, and Electrical Systems Deficiencies	Have power receptacles that are properly grounded.	F – Moderate Harm Potential
2021-07-29	Egress Deficiencies	Keep aisles, corridors, and exits free of obstruction in case of emergency.	E – Moderate Harm Potential
2021-07-29	Egress Deficiencies	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.	E – Moderate Harm Potential
2021-07-29	Egress Deficiencies	Have exits that are accessible at all times.	E – Moderate Harm Potential
2021-07-29	Smoke Deficiencies	Install smoke barrier doors that can resist smoke for at least 20 minutes.	E – Moderate Harm Potential
2021-07-29	Gas, Vacuum, and Electrical Systems Deficiencies	Have proper medical gas storage and administration areas.	E – Moderate Harm Potential
2021-07-29	Services Deficiencies	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	D – Moderate Harm Potential

Total Penalties & Fines

$63,469

Total Fine Amount (CMS)

Number of Fines

Total Penalties

Date	Type	Fine Amount	Payment Denial
2023-12-13	Fine	$63,469	-

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