01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-06-04 | 4 | 2025-06-04 | 5 |
| Cycle 2 | 2023-12-13 | 11 | 2023-12-13 | 3 |
| Cycle 3 | 2021-07-29 | 8 | 2021-07-29 | 6 |
CMS CCN 3150502026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Complete Care At Burlington Woods, Llc
115 Sunset Road · Burlington, NJ 08016 · Burlington County
Certified beds215CMS provider file
Recent citation rows37current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
37 rows in the current release
1 rows carry G–L scope/severity codes; 0 carry J–L. 5 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-01-27 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2026-02-13 · complaint2025-06-04 · HEALTHF0658Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2025-07-11 · complaint2025-06-04 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2025-07-112025-06-04 · HEALTHF0732Severity D · isolated; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Correction field: Deficient, Provider has date of correction · 2025-07-112025-06-04 · FIREK0281Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Install proper backup exit lighting.
Correction field: Deficient, Provider has date of correction · 2025-07-112025-06-04 · FIREK0324Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2025-07-112025-06-04 · FIREK0363Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2025-07-112025-06-04 · FIREK0374Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Correction field: Deficient, Provider has date of correction · 2025-07-112025-06-04 · FIREK0521Severity F · widespread; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2025-07-112023-12-13 · HEALTHF0584Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-01-26 · complaint2023-12-13 · HEALTHF0585Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-01-26 · complaint2023-12-13 · HEALTHF0661Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Correction field: Deficient, Provider has date of correction · 2024-01-26 · complaint2023-12-13 · HEALTHF0677Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2024-01-26 · complaint2023-12-13 · HEALTHF0686Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2024-01-26 · complaint2023-12-13 · HEALTHF0689Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2024-01-052023-12-13 · HEALTHF0691Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2024-01-26 · complaint2023-12-13 · HEALTHF0725Severity E · pattern; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Correction field: Deficient, Provider has date of correction · 2024-01-26 · complaint2023-12-13 · HEALTHF0804Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Correction field: Deficient, Provider has date of correction · 2024-01-26 · complaint2023-12-13 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2024-01-262023-12-13 · HEALTHF0865Severity E · pattern; potential for more than minimal harm
Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
Correction field: Deficient, Provider has date of correction · 2024-01-262023-12-13 · HEALTHF0867Severity F · widespread; potential for more than minimal harm
Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Correction field: Deficient, Provider has date of correction · 2024-01-262023-12-13 · HEALTHF0868Severity D · isolated; potential for more than minimal harm
Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Correction field: Deficient, Provider has date of correction · 2024-01-262023-12-13 · HEALTHF0924Severity E · pattern; potential for more than minimal harm
Environmental Deficiencies
Put firmly secured handrails on each side of hallways.
Correction field: Deficient, Provider has date of correction · 2024-01-262023-12-13 · FIREK0311Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have an enclosure around a vertical opening shaft.
Correction field: Deficient, Provider has date of correction · 2024-01-2603 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2023-12-13 | Fine | $63,469 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- PC NJ1 OPCOS LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 07/01/2021
- PC WTA OPCO HOLDCO LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 07/01/2021
- SMS 2021 TRUSTOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 07/01/2021
- STEIN, SHALOMIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 07/01/2021
- WELLTOWER INCOrganization · 5% OR GREATER SECURITY INTERESTNOT APPLICABLE · since 07/01/2021
- HOCH, ROBERTIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 07/01/2021
- STEIN, SHALOMIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 07/01/2021
- STEIN, SHALOMIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/01/2021
- GOLDMAN, ELIYAHUIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2021
- HOCH, ROBERTIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2021
- MERCADO, WANDAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2021
- ROSENZWEIG, ALANIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2021
- SOLARZ, JEFFREYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2021
- STEIN, SHALOMIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 07/01/2021
- AURORA GUARDIAN HOLDCO II CO-BORROWER, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/01/2021
- AURORA GUARDIAN HOLDCO II MEZZ BORROWER, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/01/2021
- AURORA GUARDIAN HOLDCO II, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/01/2021
- AURORA GUARDIAN II REALTY, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/01/2021
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.56per resident day
RN hours0.41per resident day
Weekend nurse hours3.27per resident day
Staff turnover41.7%CMS reported field
06 / LOCAL RECORDS
Open the Burlington ledger →