Inspection Reports for
Masonic Village At Burlington
902 Jacksonville Road, Burlington, NJ, 08016
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
43% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Notice
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
This document serves as a Notice of Privacy Practices informing individuals about how their medical information may be used and disclosed by NJDHSS, and outlining their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individual rights regarding their health data, and legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director | NJDHSS Privacy Officer named as contact for privacy practices |
Inspection Report
Annual Inspection
Census: 113
Capacity: 264
Deficiencies: 7
Date: Mar 28, 2025
Visit Reason
A recertification and Life Safety Code survey was conducted at Masonic Village at Burlington from 3/21/25 through 3/28/25 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Complaint Details
Complaint investigation was conducted based on complaints NJ 174543, NJ 174805, and NJ 179076. The facility was found not in compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey. Immediate Jeopardy was identified related to abuse and neglect.
Findings
The facility was found to be in noncompliance with several requirements including freedom from abuse and neglect, infection prevention and control, physician visits, therapeutic diets, and life safety code violations. Immediate Jeopardy was identified related to abuse and neglect. Corrective action plans were accepted and verified on-site.
Deficiencies (7)
Failure to protect residents from abuse and neglect, including failure to investigate incidents and remove involved staff immediately.
Failure to ensure therapeutic diets were prescribed by the attending physician.
Failure to ensure timely and adequate physician visits for residents.
Failure to maintain means of egress free of obstructions and ensure fire doors self-close and latch properly.
Failure to ensure fire sprinkler systems were inspected and tested as required.
Failure to ensure infection prevention and control program was implemented effectively, including hand hygiene and PPE use.
Failure to ensure safe storage and segregation of oxygen cylinders and combustible materials.
Report Facts
Census: 113
Total Capacity: 264
Deficiency counts: 8
Date of survey completion: Mar 28, 2025
Date of follow-up verification: Apr 21, 2025
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 3
Date: Oct 15, 2024
Visit Reason
The inspection was conducted in response to Complaint #NJ00178000 with survey dates on 10/8/24, 10/10/24, and 10/15/24 to investigate allegations related to resident care and dietary services at Masonic Village at Burlington.
Complaint Details
Complaint #NJ00178000 triggered the investigation. The Immediate Jeopardy was identified on 10/10/24 at 8:13 p.m. and was addressed with a Removal Plan implemented on 10/11/24. The Immediate Jeopardy was downgraded to a D level with no actual harm after corrective actions.
Findings
The facility was found to have failed to implement a comprehensive care plan for Resident #2, resulting in an Immediate Jeopardy situation due to improper meal service and supervision. The facility also failed to provide a safe environment free from accident hazards and failed to ensure therapeutic diets were prescribed and followed as ordered by the physician. A Removal Plan was implemented and verified to address these deficiencies.
Deficiencies (3)
Failure to develop and implement a comprehensive person-centered care plan for Resident #2, resulting in an Immediate Jeopardy situation.
Failure to provide adequate supervision and assistance devices to prevent accidents for Resident #2.
Failure to ensure therapeutic diets were prescribed by the attending physician and followed for Resident #2.
Report Facts
Survey Dates: 10/8/24, 10/10/24, 10/15/24
Sample Size: 4
Deficiency Completion Date: 10/15/24
Immediate Jeopardy Identification Time: 10/10/24 at 8:13 p.m.
Resident Census: 116
Brief Interview for Mental Status (BIMS) Score: 15
Temperature: 178.5
Number of Residents Requiring Assistance: 36
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 1
Date: Aug 22, 2024
Visit Reason
The inspection was conducted based on a complaint visit (Complaint #: NJ168631) to assess compliance with federal and state regulations regarding staffing ratios in the facility.
Complaint Details
Complaint #: NJ168631. The facility was found deficient in staffing ratios on 1 of 14 evening shifts. The complaint was substantiated as the deficiency was confirmed by review of staffing records.
Findings
The facility was found to be in substantial compliance overall but failed to meet the required minimum staff-to-resident ratios for Certified Nurse Aides (CNAs) on 1 of 14 evening shifts reviewed. Specifically, on 10/11/23, there were 7 CNAs instead of the required 9 for the evening shift. The facility submitted a plan of correction and demonstrated corrective actions.
Deficiencies (1)
Failed to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 1 of 14 evening shifts.
Report Facts
Census: 115
Deficient shifts: 1
Staffing ratio: 7
Required CNAs: 9
Inspection Report
Annual Inspection
Census: 84
Capacity: 264
Deficiencies: 6
Date: Jun 30, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including complaint investigations and review of professional standards of practice.
Complaint Details
Complaint NJ #: 159009; 160807; 161324; 162044 were investigated during the recertification survey.
Findings
Deficiencies were cited related to failure to meet professional standards in care plan documentation and medication administration, respiratory care and oxygen therapy, medication labeling and storage, emergency lighting, interior wall finishes, and fire alarm system maintenance.
Deficiencies (6)
Failure to clarify and accurately transcribe physician's orders and document administration of treatments for residents, including feeding tube management.
Failure to ensure respiratory equipment was kept clean and sanitary, and develop individualized care plan for oxygen administration and treatment.
Failure to properly label and date opened medication vials (Tubersol) in medication storage.
Failure to provide battery backup emergency lighting above transfer switches independent of building electrical system and emergency generator.
Failure to ensure interior wall finishes in exit corridors meet flame spread rating requirements; carpeted walls lacked documentation of compliance.
Failure to maintain fire alarm system in accordance with NFPA 70 and 72; main fire alarm panel was in trouble mode due to ground faults and telephone line trouble.
Report Facts
Census: 84
Total Capacity: 264
Deficiency Completion Dates: Jul 28, 2023
Medication Vials: 2
Emergency Lighting Duration: 90
Carpet Wall Height: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Licensed Practical Nurse | Interviewed regarding feeding tube care and documentation |
| Unit Manager/Licensed Practical Nurse (UM/LPN #1) | Unit Manager/Licensed Practical Nurse | Interviewed regarding responsibility for transcribing physician orders |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding documentation and professional standards of care |
| Licensed Nursing Home Administrator (LNHA) | Licensed Nursing Home Administrator | Interviewed regarding medication order documentation and oxygen tank storage |
| Consultant Pharmacist (CP) | Consultant Pharmacist | Interviewed regarding medication labeling and tube feeding protocols |
| Registered Dietician (RD) | Registered Dietician | Interviewed regarding tube feeding monitoring and orders |
| Neighborhood Manager (NM) | Neighborhood Manager | Interviewed regarding portable oxygen storage |
| Registered Nurse (RN) | Registered Nurse | Interviewed regarding medication storage and care planning |
| Maintenance Director (MD) | Maintenance Director | Interviewed regarding emergency lighting and fire alarm system |
| Unit Manager/Registered Nurse (UM/RN) | Unit Manager/Registered Nurse | Interviewed regarding medication vial labeling |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jun 30, 2023
Visit Reason
The visit was a follow-up to verify correction of previously cited deficiencies related to emergency lighting, interior wall and ceiling finishes, and fire alarm system maintenance.
Findings
The facility had previously failed to provide battery backup emergency lighting above transfer switches, ensure interior wall finishes met flame spread ratings, and maintain the fire alarm system properly. The follow-up confirmed that corrective actions were completed by 07/28/2023, including installation of emergency lighting, removal of carpet wall coverings, and addressing fire alarm panel troubles.
Deficiencies (3)
Failed to provide battery backup emergency light above three transfer switches independent of the building's electrical system and emergency generator.
Failed to ensure interior wall finishes were Class A or Class B in egress corridors; carpet installed on walls lacked documentation of flame spread rating.
Failed to maintain fire alarm system in accordance with NFPA 70 and 72; main fire alarm panel was in trouble mode due to ground faults and telephone line trouble.
Report Facts
Deficiencies cited: 3
Correction completion date: Jul 28, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during observations and interviews related to emergency lighting and fire alarm system deficiencies | |
| Licensed Nursing Home Administrator | Informed of findings at Life Safety Code exit and exit conference | |
| Director of Facility Services | Directed corrective actions and staff training related to deficiencies |
Inspection Report
Abbreviated Survey
Census: 78
Deficiencies: 0
Date: Dec 21, 2022
Visit Reason
Focused Infection Control Survey conducted by the New Jersey Department of Health on 12/21/2022 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 the CMS and CDC recommended practices.
Report Facts
Sample size: 6
Inspection Report
Life Safety
Deficiencies: 0
Date: Oct 31, 2022
Visit Reason
A Life Safety Code Survey was conducted as part of a New Renovation Project involving installation of secured doors and cosmetic upgrades to the 3rd Floor South Building.
Findings
The facility was found to be in compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 Edition of the NFPA 101 Life Safety Code, Chapter 19 Existing Health Care Occupancies for this project. The noted areas may not be occupied until formal notification by the Certificate of Need and Licensing Division is received.
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 1
Date: Sep 1, 2021
Visit Reason
The inspection was conducted based on complaint NJ146664 to investigate allegations related to medication administration and compliance with physician's orders.
Complaint Details
Complaint NJ146664 triggered the visit. The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B based on this complaint visit.
Findings
The facility was found not in substantial compliance due to failure to follow physician's orders and facility policy on medication administration for one resident, resulting in missed medication doses and inconsistent documentation. The resident experienced weight gain potentially related to the medication errors. The facility implemented corrective actions including staff education, monitoring, and auditing.
Deficiencies (1)
Failure to follow Physician's Orders for medication administration and facility policy titled 'Medication Administration' for one resident, resulting in missed doses and inconsistent documentation.
Report Facts
Sample Size: 3
Weight documentation missing days: 4
Resident census: 101
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Provided interview details about the medication administration issue and resident condition. |
| Director of Nursing | Director of Nursing (DON) | Provided interview details regarding resident's weight gain and medication administration. |
| Nurse Manager | Nurse Manager | Noticed missing weight documentation and oversaw corrective actions including staff counseling and education. |
Inspection Report
Annual Inspection
Census: 96
Deficiencies: 0
Date: May 20, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with the recertification survey to assess compliance with infection control regulations.
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, including compliance with COVID-19 infection control regulations as recommended by CMS and CDC.
Report Facts
Sample size: 23
Inspection Report
Life Safety
Deficiencies: 2
Date: May 18, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 05/18/2021 and 05/20/2021 to assess compliance with Medicare/Medicaid participation requirements related to fire safety and life safety codes.
Findings
The facility was found to be in noncompliance with the 2012 NFPA 101 Life Safety Code, specifically regarding inadequate automatic sprinkler protection in the soiled linen room and failure to monitor emergency electrical system annunciator panels 24 hours a day.
Deficiencies (2)
Failed to provide automatic fire sprinkler protection to the subdivided soiled linen room #070C; sprinkler head elevated 2 inches above drop ceiling and no sprinkler head in lower level of the room.
Failed to monitor emergency electrical system remote annunciator panels 24 hours per day in accordance with NFPA 99.
Report Facts
Date survey completed: May 20, 2021
Sprinkler system correction completion date: May 19, 2021
Electrical system correction completion date: Jul 31, 2021
Number of emergency generators: 7
Soiled linen room lower level dimensions: 50
Soiled linen room second area dimensions: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Manager | Interviewed and confirmed sprinkler and annunciator panel issues | |
| Administrator | Notified of deficiencies at Life Safety Code exit conference on 05/20/2021 | |
| Director of Facility Services | Directed corrective actions and staff inservicing related to sprinkler and annunciator panel compliance |
Inspection Report
Routine
Census: 82
Deficiencies: 0
Date: Jan 22, 2021
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 related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 3
Inspection Report
Routine
Census: 96
Deficiencies: 0
Date: Dec 10, 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 related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Inspection Report
Abbreviated Survey
Census: 106
Deficiencies: 0
Date: Nov 19, 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 has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 3
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