Burlington, NJ

Complete Care At Marcella LLC

5-star overall rating with 4-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

2305 Rancocas Road, Burlington, NJ

(609) 387-9300

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

150

Certified beds

Average residents

142

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Complete Care

Operator or chain grouping

Approved since

1994-05-02

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

0.42

Registered nurse staffing · state 0.69 · national 0.68

LPN hours / resident day

1.11

Licensed practical nurse staffing · state 0.94 · national 0.87

Aide hours / resident day

1.97

Nurse aide staffing · state 2.23 · national 2.35

Total nurse hours

3.51

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.53

RN + LPN hours · state 1.62 · national 1.54

Weekend hours

3.09

Weekend nurse staffing · state 3.45 · national 3.43

Weekend RN hours

0.27

Weekend registered nurse coverage · state 0.49 · national 0.47

Physical therapist

0.07

Reported PT staffing · state 0.11 · national 0.07

Adjusted RN hours

0.44

CMS adjusted RN staffing hours

Adjusted total hours

3.61

CMS adjusted total nurse staffing hours

Case-mix index

1.33

Higher values indicate more complex resident acuity

RN turnover

31%

Annual RN turnover · state 39% · national 45%

Total nurse turnover

39%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,945

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

18.54

Composite VBP score used to determine payment impact.

Payment multiplier

0.9820

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Baseline 21.94% · Performance 22.00% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

1.07

Baseline 6.10% · Performance 7.52% · Measure score 1.07 · Achievement 1.07 · Improvement 0

Total nurse turnover

4.31

Baseline 45.00% · Performance 46.04% · Measure score 4.31 · Achievement 4.31 · Improvement 0

Adjusted total nurse staffing

2.04

Baseline 3.81 hours · Performance 3.66 hours · Measure score 2.04 · Achievement 2.04 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.01%	10.72% 0.7 pts better	No Different than the National Rate · Eligible stays 180 · Observed rate 9.44% · Lower 95% interval 7.18%
Discharge to community	49.1%	50.57% 1.5 pts worse	No Different than the National Rate · Eligible stays 185 · Observed rate 41.62% · Lower 95% interval 42.1%
Medicare spending per beneficiary	1.42	1.02 0.4 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 192 · Denominator 192
Falls with major injury	0.52%	0.77% 0.2 pts better	Numerator 1 · Denominator 192
Discharge self-care score	68.42%	53.69% 14.7 pts better	Numerator 65 · Denominator 95
Discharge mobility score	62.11%	50.94% 11.2 pts better	Numerator 59 · Denominator 95
Pressure ulcers or injuries, new or worsened	0.52%	2.29% 1.8 pts better	Numerator 1 · Denominator 192 · Adjusted rate 0.43%
Healthcare-associated infections requiring hospitalization	7.52%	7.12% 0.4 pts worse	No Different than the National Rate · Eligible stays 151 · Observed rate 7.95% · Lower 95% interval 5.42%
Staff COVID-19 vaccination coverage	0.56%	8.2% 7.6 pts worse	Numerator 1 · Denominator 178
Staff flu vaccination coverage	97.24%	42% 55.2 pts better	Numerator 247 · Denominator 254
Discharge function score	65.26%	56.45% 8.8 pts better	Numerator 62 · Denominator 95
Transfer of health information to provider	98.55%	95.95% 2.6 pts better	Numerator 68 · Denominator 69
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 76 · Denominator 76
Resident COVID-19 vaccinations up to date	39.29%	25.2% 14.1 pts better	Numerator 33 · Denominator 84

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.0	2.1 1.1 pts better	1.9 0.9 pts better	Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.2 · Expected 2.2 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.0	1.1 0.1 pts better	1.8 0.8 pts better	Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.6%	93.0% 6.6 pts better	93.4% 6.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 99.1% · Q2 99.1% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	97.2% 2.8 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	0.4%	2.4% 2 pts better	3.3% 2.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.8% · Q4 0.9% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	10.8%	11.4% 0.6 pts better	11.4% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 8.9% · Q3 1.8% · Q4 12.1% · 4Q avg 10.8%
Percentage of long-stay residents who lose too much weight	1.9%	4.6% 2.7 pts better	5.4% 3.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.0% · Q3 0.9% · Q4 1.0% · 4Q avg 1.9%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	18.9%	19.0% 0.1 pts better	19.6% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 20.8% · Q3 18.7% · Q4 17.0% · 4Q avg 18.9%
Percentage of long-stay residents who received an antipsychotic medication	12.6%	13.5% 0.9 pts better	16.7% 4.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 23.0% · Q3 9.5% · Q4 6.1% · 4Q avg 12.6% · 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	5.1%	9.8% 4.7 pts better	16.3% 11.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 10.4% · Q3 0.0% · Q4 2.2% · 4Q avg 5.1% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	4.4%	9.7% 5.3 pts better	14.9% 10.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 6.5% · Q3 4.0% · Q4 2.1% · 4Q avg 4.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.2%	0.7% 0.5 pts better	1.0% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.7% · 4Q avg 0.2% · 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	30.6%	15.9% 14.7 pts worse	19.8% 10.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 32.6% · Q2 37.3% · Q3 28.8% · Q4 23.8% · 4Q avg 30.6%
Percentage of long-stay residents with pressure ulcers	3.9%	6.0% 2.1 pts better	5.1% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 3.2% · Q3 3.9% · Q4 5.8% · 4Q avg 3.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	96.4%	78.7% 17.7 pts better	81.7% 14.7 pts better	Short Stay · 2024Q4-2025Q3 · Q1 96.2% · Q2 95.3% · Q3 95.1% · Q4 98.9% · 4Q avg 96.4%
Percentage of short-stay residents who had an outpatient emergency department visit	6.2%	8.2% 2 pts better	12.0% 5.8 pts better	Short Stay · 20240701-20250630 · Adjusted 6.2% · Observed 6.1% · Expected 11.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.7%	1.2% 0.5 pts better	1.6% 0.9 pts better	Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	93.4%	80.1% 13.3 pts better	79.7% 13.7 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 93.4%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	23.9%	25.4% 1.5 pts better	23.9% About the same	Short Stay · 20240701-20250630 · Adjusted 23.9% · Observed 25.5% · Expected 25.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-07-24 · Fire 2025-07-24

2 health deficiencies

Top issue: Infection Control (1 deficiency)

4 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2023-11-21 · Fire 2023-11-21

9 health deficiencies

Top issue: Resident Assessment and Care Planning (4 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 3 Health 2021-08-11 · Fire 2021-08-11

4 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-07-24

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2025-09-01

E · Potential for more than minimal harm 2025-07-24

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-09-01

E · Potential for more than minimal harm 2025-07-24

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-09-01

D · Potential for more than minimal harm 2025-07-24

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2025-09-01

F · Potential for more than minimal harm 2023-11-21

K362 · Smoke Deficiencies

Fire Safety

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Corrected 2023-12-21

E · Potential for more than minimal harm 2021-08-11

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2021-11-01

D · Potential for more than minimal harm 2021-08-11

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2021-11-01

D · Potential for more than minimal harm 2021-08-11

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2021-11-01

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-07-24

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-09-01

D · Potential for more than minimal harm 2025-07-24

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-09-01

E · Potential for more than minimal harm 2025-01-21

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-02-21

D · Potential for more than minimal harm 2024-06-07

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-07-05

F · Potential for more than minimal harm 2023-11-21

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 2023-12-21

E · Potential for more than minimal harm 2023-11-21