Cycle 1
Health 2025-06-04 · Fire 2025-06-04
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Burlington, NJ
Complete Care At Burlington Woods, LLC
3-star overall rating with 3-star inspections with $63,469 in total fines with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
115 Sunset Road, Burlington, NJ
(609) 387-3620
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
215
Certified beds
Average residents
171
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1976-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
85 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.58
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.09
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.48
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.39
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.16
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.58
CMS adjusted RN staffing hours
Adjusted total hours
3.46
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,632
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.21
Composite VBP score used to determine payment impact.
Payment multiplier
0.9869
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.37
Baseline 18.54% · Performance 20.80% · Measure score 1.37 · Achievement 1.37 · Improvement 0
Healthcare-associated infections
4.56
Baseline 5.85% · Performance 6.47% · Measure score 4.56 · Achievement 4.56 · Improvement 0
Total nurse turnover
5.42
Baseline 55.08% · Performance 41.52% · Measure score 5.42 · Achievement 5.42 · Improvement 3.99
Adjusted total nurse staffing
1.53
Baseline 3.98 hours · Performance 3.51 hours · Measure score 1.53 · Achievement 1.53 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.97% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 130 · Observed rate 10% · Lower 95% interval 7.33% |
| Discharge to community | 52.24% |
50.57%
1.7 pts better
|
No Different than the National Rate · Eligible stays 143 · Observed rate 42.66% · Lower 95% interval 45.76% |
| Medicare spending per beneficiary | 1.3 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 126 · Denominator 126 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 126 |
| Discharge self-care score | 59.76% |
53.69%
6.1 pts better
|
Numerator 49 · Denominator 82 |
| Discharge mobility score | 47.56% |
50.94%
3.4 pts worse
|
Numerator 39 · Denominator 82 |
| Pressure ulcers or injuries, new or worsened | 1.59% |
2.29%
0.7 pts better
|
Numerator 2 · Denominator 126 · Adjusted rate 1.75% |
| Healthcare-associated infections requiring hospitalization | 6.47% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 79 · Observed rate 6.33% · Lower 95% interval 3.51% |
| Staff COVID-19 vaccination coverage | 1.15% |
8.2%
7 pts worse
|
Numerator 2 · Denominator 174 |
| Staff flu vaccination coverage | 97.71% |
42%
55.7 pts better
|
Numerator 213 · Denominator 218 |
| Discharge function score | 63.41% |
56.45%
7 pts better
|
Numerator 52 · Denominator 82 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 34 · Denominator 34 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 56 · Denominator 56 |
| Resident COVID-19 vaccinations up to date | 8.75% |
25.2%
16.4 pts worse
|
Numerator 7 · Denominator 80 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.1
0.3 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.8 · Expected 3.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.1
0.4 pts worse
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 2.0 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.4% |
93.0%
3.4 pts better
|
93.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 97.2% · Q3 96.7% · Q4 93.3% · 4Q avg 96.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.4% |
97.2%
2.2 pts better
|
95.5%
3.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
2.4%
0.3 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.1% · Q3 2.0% · Q4 2.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 19.3% |
11.4%
7.9 pts worse
|
11.4%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 19.7% · Q3 22.4% · Q4 20.6% · 4Q avg 19.3% |
| Percentage of long-stay residents who lose too much weight | 1.3% |
4.6%
3.3 pts better
|
5.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.3% · Q3 0.7% · Q4 0.7% · 4Q avg 1.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.5% |
19.0%
3.5 pts worse
|
19.6%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 23.3% · Q3 21.8% · Q4 22.1% · 4Q avg 22.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.2% |
13.5%
3.7 pts worse
|
16.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 21.8% · Q3 16.0% · Q4 14.9% · 4Q avg 17.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 3.4% |
9.8%
6.4 pts better
|
16.3%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 2.1% · Q3 3.3% · Q4 0.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.3% |
9.7%
6.4 pts better
|
14.9%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 5.8% · Q3 2.2% · Q4 1.5% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.1% |
0.7%
0.6 pts better
|
1.0%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.1% |
15.9%
2.2 pts worse
|
19.8%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 14.4% · Q3 27.5% · Q4 14.6% · 4Q avg 18.1% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
6.0%
About the same
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 6.4% · Q3 4.3% · Q4 6.5% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.7% |
78.7%
11 pts better
|
81.7%
8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.4% · Q2 92.7% · Q3 87.8% · Q4 85.4% · 4Q avg 89.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.9% |
8.2%
4.7 pts worse
|
12.0%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.9% · Observed 14.0% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.2%
0.2 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 1.0% · Q3 0.0% · Q4 1.1% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.6% |
80.1%
16.5 pts better
|
79.7%
16.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.5% |
25.4%
2.1 pts worse
|
23.9%
3.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.5% · Observed 29.1% · Expected 25.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-13 · Fire 2023-12-13
11 health deficiencies
Top issue: Administration (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2021-07-29 · Fire 2021-07-29
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-04
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-07-11
F · Potential for more than minimal harm
2025-06-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-11
F · Potential for more than minimal harm
2025-06-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-07-11
F · Potential for more than minimal harm
2025-06-04
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-07-11
F · Potential for more than minimal harm
2025-06-04
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-07-11
F · Potential for more than minimal harm
2023-12-13
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-01-26
F · Potential for more than minimal harm
2023-12-13
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-01-26
F · Potential for more than minimal harm
2023-12-13
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-01-26
E · Potential for more than minimal harm
2021-07-29
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-08-30
E · Potential for more than minimal harm
2021-07-29
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2021-08-30
E · Potential for more than minimal harm
2021-07-29
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2021-08-30
E · Potential for more than minimal harm
2021-07-29
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-08-30
E · Potential for more than minimal harm
2021-07-29
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-08-30
D · Potential for more than minimal harm
2021-07-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-08-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-13
D · Potential for more than minimal harm
2025-06-04
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-07-11
D · Potential for more than minimal harm
2025-06-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-11
D · Potential for more than minimal harm
2025-06-04
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-07-11
G · Actual harm
2023-12-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-05
F · Potential for more than minimal harm
2023-12-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-26
F · Potential for more than minimal harm
2023-12-13
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-01-26
E · Potential for more than minimal harm
2023-12-13
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-01-26
E · Potential for more than minimal harm
2023-12-13
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-01-26
E · Potential for more than minimal harm
2023-12-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-26
E · Potential for more than minimal harm
2023-12-13
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-01-26
E · Potential for more than minimal harm
2023-12-13
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-01-26
E · Potential for more than minimal harm
2023-12-13
F924 · Environmental Deficiencies
Health
Put firmly secured handrails on each side of hallways.
Corrected 2024-01-26
D · Potential for more than minimal harm
2023-12-13
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2024-01-26
D · Potential for more than minimal harm
2023-12-13
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-01-26
D · Potential for more than minimal harm
2023-12-13
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2024-01-26
D · Potential for more than minimal harm
2023-12-13
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-01-26
D · Potential for more than minimal harm
2023-12-13
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-01-26
F · Potential for more than minimal harm
2021-07-29
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-08-30
D · Potential for more than minimal harm
2021-07-29
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2021-08-30
D · Potential for more than minimal harm
2021-07-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-08-30
D · Potential for more than minimal harm
2021-07-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-08-30
D · Potential for more than minimal harm
2021-07-29
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2021-08-30
Penalties and ownership
What sits behind the stars
$63,469
2023-12-13
Fine
Fine · fine $63,469
Fine
Ownership
Pc Nj1 Opcos LLC
5% Or Greater Direct Ownership Interest · Organization
Goldman, Eliyahu
Operational/Managerial Control · Individual
Hoch, Robert
Operational/Managerial Control · Individual
Mercado, Wanda
Operational/Managerial Control · Individual
Pc Wta Opco Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Peace Capital Holdings LLC (De)
5% Or Greater Indirect Ownership Interest · Organization
Rosenzweig, Alan
Operational/Managerial Control · Individual
Sms 2021 Trust
5% Or Greater Indirect Ownership Interest · Organization
Solarz, Jeffrey
Operational/Managerial Control · Individual
Stein, Shalom
Corporate Officer · Individual
Welltower Inc
5% Or Greater Security Interest · Organization
Nearby options
Other facilities in reach
#1
Complete Care At Marcella LLC
Burlington, NJ
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Masonic Village At Burlington
Burlington, NJ
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $86,411 in total fines with 8 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Bristol Health & Rehab Center
Bristol, PA
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $418,359 in total fines with 25 recent health deficiencies
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