Inspection Reports for
Complete Care At Burlington Woods

Complaint #2698562 was substantiated based on interviews, record review, and facility documents indicating failure to provide adequate assessment and care after family reported resident's decline.

The facility failed to provide adequate assessment and needed care for Resident #2, including lack of documentation of nursing assessments and failure to administer insulin according to a standing sliding scale order for high blood sugar. The Registered Nurse Supervisor did not document her assessment, and there was no clear physician notification or orders documented regarding the elevated blood sugar.

Complaint #NJ 172662 was substantiated based on interviews, medical record reviews, and facility documentation showing multiple late administrations of oxycodone for Resident #269.

The facility failed to administer oxycodone medication within the scheduled times on multiple occasions for one resident reviewed, resulting in minimal harm or potential for actual harm to a few residents. The facility's policy allows a one-hour window before or after scheduled medication times, but multiple doses were administered outside this timeframe.

Complaint #NJ 172662 was substantiated based on interviews, medical record reviews, and facility documentation showing medication administration delays and improper respiratory equipment storage.

The facility was found deficient in administering medications on time for one resident, failing to properly store and maintain nebulizer equipment for two residents, and not posting updated nurse staffing information daily. All deficiencies were determined to cause minimal harm or potential for actual harm affecting a few residents.

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.

Complaints NJ 149879, NJ 151052, NJ 151398, NJ 152112, NJ 152052, NJ 152420, NJ 153704 were investigated involving issues of resident care, environment, grievance handling, discharge procedures, wound care, staffing, and food service.

The facility was found deficient in maintaining a safe, clean, and homelike environment, timely and appropriate resident care including incontinence and nail care, grievance investigation, discharge planning, wound care and prevention, colostomy care, food palatability and temperature, and adequate staffing levels.

Complaint numbers NJ 152052, NJ 152420, NJ 153704, NJ 151052, NJ 152112, NJ 149879, NJ 151398.

The facility failed to maintain a safe, clean, and homelike environment, provide adequate activities of daily living care, prevent and treat pressure ulcers, ensure adequate supervision to prevent falls, maintain sufficient staffing levels, provide palatable and properly temperature-controlled food, maintain sanitary food storage, and conduct effective quality assurance and performance improvement activities.

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.

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.

The facility was found deficient in maintaining a safe, clean, and homelike environment, proper treatment and care including application of protective sleeves, nutritional assessment and intervention for significant weight loss, accurate controlled medication accountability and valid DEA registration, and proper food handling and infection control practices in the kitchen.

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.

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.