Inspection Reports for Complete Care At Burlington Woods, Llc
115 Sunset Road, NJ, 08016
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Notice
Deficiencies: 0
Nov 19, 2025
Visit Reason
This document serves to inform covered components and the public about the privacy practices related to medical information handled by NJDHSS, including how information may be used, disclosed, and the rights of individuals.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Routine
Census: 148
Deficiencies: 10
Dec 13, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, based on multiple complaints received.
Findings
The facility was found not to be in substantial compliance with requirements for long term care facilities based on deficiencies cited related to safe environment, grievance procedures, discharge summary, activities of daily living, treatment and prevention of pressure ulcers, colostomy care, sufficient nursing staff, nutrition and food safety, quality assurance, and life safety code violations.
Deficiencies (10)
| Description |
|---|
| Safe/Clean/Comfortable/Homelike Environment deficiencies including failure to maintain safe, clean, comfortable environment and housekeeping issues. |
| Grievance procedures not properly followed; failure to investigate and resolve grievances timely and appropriately. |
| Discharge Summary deficiencies including failure to provide complete and accurate discharge instructions and medication reconciliation. |
| Activities of Daily Living (ADL) care deficiencies including failure to provide consistent assistance with ADLs for identified residents. |
| Treatment and Prevention of Pressure Ulcers deficiencies including failure to provide adequate care and documentation for residents with pressure ulcers. |
| Colostomy, Urostomy, or Ileostomy Care deficiencies including failure to provide appropriate care and documentation. |
| Sufficient Nursing Staff deficiencies including failure to provide adequate nursing staff to meet residents' needs. |
| Nutrition and Food Safety deficiencies including failure to provide palatable, safe food at proper temperatures and failure to properly store and label food items. |
| Quality Assurance and Performance Improvement (QAPI) program deficiencies including failure to implement effective quality assurance and performance improvement activities. |
| Life Safety Code deficiencies including failure to maintain fire-rated doors, electrical systems, and handrails in safe condition. |
Report Facts
Complaint numbers: 10
Census: 148
Date of Completion: Jan 26, 2024
Inspection Report
Routine
Census: 155
Deficiencies: 0
Feb 15, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 5
Inspection Report
Abbreviated Survey
Census: 140
Deficiencies: 1
Aug 24, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations and COVID-19 recommended practices.
Findings
The facility was found to be in compliance with federal infection control regulations in one report but not in compliance with New Jersey Administrative Code infection control regulations in another. A deficiency was identified related to failure to maintain required minimum direct care staff-to-resident ratios for day shifts on 13 of 14 days reviewed.
Deficiencies (1)
| Description |
|---|
| Failure to maintain the required minimum direct care staff-to-resident ratios for the day shifts on 13 of 14 days reviewed. |
Report Facts
Census: 140
Deficient CNA staffing days: 13
CNA staffing counts: 16
CNA staffing counts: 16
CNA staffing counts: 15
CNA staffing counts: 16
CNA staffing counts: 16
CNA staffing counts: 16
CNA staffing counts: 9
CNA staffing counts: 14
CNA staffing counts: 15
CNA staffing counts: 13
CNA staffing counts: 14
CNA staffing counts: 11
CNA staffing counts: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Human Resource Director | Stated that the staff-to-resident ratios were 1:8 on day shift, 1:10 on evenings and 1:14 on night shift during interview on 08/24/22. |
Inspection Report
Abbreviated Survey
Census: 39
Deficiencies: 1
Jan 25, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations and staffing requirements.
Findings
The facility was found not to be in compliance with New Jersey Administrative Code infection control regulations and failed to maintain the required minimum direct care staff to resident ratios for 14 of 14 day shifts reviewed.
Deficiencies (1)
| Description |
|---|
| Failure to maintain the required minimum direct care staff to resident ratios as mandated by the state of New Jersey for 14 of 14 day shifts reviewed. |
Report Facts
Residents on day shifts: 149
Certified Nursing Assistants (CNAs) required: 19
Certified Nursing Assistants (CNAs) present: 9
Day shifts deficient in CNA staffing: 14
Census on A-Wing day shift: 39
Nurses on A-Wing day shift: 4
CNAs on A-Wing day shift: 4
Staffing agencies used: 7
Inspection Report
Complaint Investigation
Census: 139
Deficiencies: 0
Sep 22, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00148291 and NJ00148548.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B for Long Term Care Facilities based on this complaint survey.
Complaint Details
Complaint numbers NJ00148291 and NJ00148548 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 142
Deficiencies: 0
Aug 26, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ146303 and NJ144426.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B for Long Term Care Facilities based on this complaint survey.
Complaint Details
Complaint numbers NJ146303 and NJ144426 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 1
Jul 29, 2021
Visit Reason
The inspection was conducted in response to Complaint #: NJ 144426 regarding the facility's compliance with New Jersey Administrative Code standards for licensure of long term care facilities, specifically related to staffing ratios.
Findings
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. Staffing reports and observations confirmed multiple dates and shifts where minimum staffing requirements were not met.
Complaint Details
Complaint #: NJ 144426. The facility was found not in compliance with staffing ratio requirements. Interviews with staffing coordinator, Director of Nursing, and Administrator confirmed ongoing staffing shortages and efforts to recruit and retain staff. The complaint was substantiated by observations and documentation.
Deficiencies (1)
| Description |
|---|
| Failure to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. |
Report Facts
Census on E wing: 54
Census on A wing: 32
Number of CNAs on A wing: 2
Number of CNAs on E wing: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding staffing shortages and recruitment efforts |
| Administrator | Administrator | Interviewed regarding staffing concerns and recruitment strategies |
| Staffing Coordinator | Staffing Coordinator | Interviewed regarding awareness of staffing ratios and challenges |
Inspection Report
Complaint Investigation
Census: 140
Deficiencies: 0
Jun 1, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ132672, NJ133837, NJ137168, NJ139258, and NJ142308.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Complaint Details
The survey was triggered by multiple complaints as listed, and the facility was found compliant with no deficiencies cited.
Report Facts
Sample Size: 8
Inspection Report
Complaint Investigation
Census: 129
Deficiencies: 0
Dec 14, 2020
Visit Reason
The inspection was conducted in response to complaints #NJ132643 and #NJ141682 to assess compliance with regulatory requirements.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint numbers NJ132643 and NJ141682 were investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 4
Inspection Report
Routine
Census: 125
Deficiencies: 0
Nov 27, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations and recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 3
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