Complete Care at Burlington Woods, LLC

Inspectors wroteComplaint #2698562Based on interviews, record review of the medical records, and other pertinent facility documents on 1/27/26, it was determined that the facility failed to provide adequate assessment and to provide needed care or services to manage resident's symptoms in accordance with professional standards of practice; after they received report from the resident's family member that the resident had decline in condition. This deficient practice was identified for 1 of 4 residents, (Resident #2) reviewed and was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; [...]

Inspectors wroteCOMPLAINT # NJ 172662 Based on interview, review of medical records and other facility documentation, it was determined that the facility failed to administer medications within scheduled parameters on various shifts in accordance with professional standards of practice. This deficient practice was identified for 1 of 34 residents reviewed for professional standards of practice (Resident #269). Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: [...]

Inspectors wroteBased on observation, interview, medical record review and review of other pertinent facility documentation, it was determined that the facility failed to 1.) contain nebulizer (a machine used to administer medication in the form of a mist inhaled into the lungs) delivery systems in protective coverings and 2.) ensure a nebulizer was stored appropriately to prevent the potential spread of infection in accordance with the Center for Disease Control (CDC) guidelines for 2 of 4 residents (Resident #99 and Resident #151) reviewed for respiratory care. This deficient practice was evidenced by the following: 1. On 5/28/25 at 9:08 AM, Resident #99 was observed lying in bed and the nurse was present for morning medication administration. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to post the updated nurse staffing report daily. This deficient practice was identified on 5/27/25, and was evidenced by the following: On 5/27/25 at 9:15 AM, upon initial entrance to the facility, the surveyor observed the posted daily staffing in the lobby was dated 5/23/25. While the survey team was in the lobby awaiting the facility administration, the staffing coordinator (SC) entered the lobby and replaced the posted staffing sheet for the current day 5/27/25. At that time, the surveyor interviewed the SC who stated staffing should be posted and updated daily and should have been changed by the weekend nursing supervisors in her absence. She further acknowledged that the posting was four days old for the 5/23/25 staffing. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to: a) ensure adequate supervision was provided to a resident to prevent falls, b) follow the facility accident policy to investigate falls, and consistently initiate new fall prevention interventions in response to falls, c) ensure current care plan interventions to prevent accidents were implemented. This deficient practice occurred for 1 of 1 resident reviewed (Resident #116) for fall with major injury who was identified as being at high risk for falls, sustained multiple falls including a fall on 02/14/22 that required transfer to the emergency room which resulted in a fracture of the left proximal humerus (arm bone) and the left olecranon (bony part of elbow), and required a surgical Open Reduction and Internal Fixation (ORIF). The deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to ensure: a) potentially hazardous and perishable food items located in the refrigerator were labeled with a use by date and covered. b) staff restrained hair c) resident food storage areas were maintained in a clean and sanitary manner and food was appropriately labeled and dated with a use by date to prevent the potential for food borne illness. This deficient practice occurred in the main kitchen and 2 of 2 remote resident food pantries and was evidenced by the following: On 11/28/23 at 8:54 AM, the surveyor conducted a tour of the kitchen with Food Service Manager FSM and observed the following: 1) The walk-in refrigerator was observed with opened potentially hazardous food items that were not labeled with a used by date and expired dairy products. [...]

Inspectors wroteBased on observation, interview and document review, it was determined that the quality assessment and assurance committee (QAPI) facility failed to ensure: a) written policies and procedures were followed to ensure all adverse events were identified and investigated, b) written procedures were followed to ensure the QAPI was consistently data driven and measurable to ensure the effectiveness of the performance improvement initiative, and c) a mechanism was in place and consistently followed to obtain input from staff, residents/ resident representatives. The deficient practice had the potential to affect all residents that resided in the facility and was evidenced by the following: Refer to F584E, F585D, F677E, F686E, F689G, F924E On 11/28/23, during the initial tour of the facility, multiple surveyors observed the following: -9:40 AM: [...]

Inspectors wroteComplaint #NJ 152052, NJ 152420, NJ 153704 Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain the resident environment, equipment and living areas in a safe, sanitary, and homelike manner. This deficient practice was evidenced on 2 of 3 resident Wings (Wing A & D) and was evidenced by the following: Interviews and observations of Surveyor #2 were as follows: On 11/28/23 at 09:23 AM, upon entrance to the facility, the Director of Nursing (DON) stated that the facility had 3 wings which consisted of Wing A which was the Subacute Unit and had 50 beds, D Wing had 59 beds and E Wing had 50 beds. On 11/28/23 at 9:45 AM, an unsampled resident on D wing informed the surveyor the heat in his/her room had been broken for 4 days. The resident stated that they had been unable to sleep because of the cold. [...]

Inspectors wroteComplaint NJ# 151052, NJ #152112 Based on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to consistently provide appropriate Activities of Daily Living (ADLs) care, for residents who were dependent on staff assistance for care, by failing to provide: a) nail care, and b) incontinence care. This deficient practice was identified for 5 of 5 dependent residents (Resident # 20, 76, #101, #106 and Resident #116) reviewed for assistance with activities of daily living.

Inspectors wroteComplaint # NJ 151052 Based on observations, interviews, record review, and review of facility documentation, it was determined that the facility failed to follow the facility policy to ensure that residents who were admitted without a pressure ulcer (PU) and was identified at Mild risk for developing pressure ulcers, and a resident admitted without a PU and was identified as completely limited in ability to respond to pressure-related discomfort, were provided with care and services to prevent worsening, or development of a pressure ulcer by failing to ensure: [...]

Inspectors wroteComplaint # NJ 149879, NJ 151052, NJ 151398, NJ 152112, Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure sufficient staff were available to: a) provide timely and appropriate incontinence care for residents who were dependent on staff for Activities of Daily Living (ADLs) care, b) provide nail care for a resident who was dependent on staff for ADLs, and c) provide colostomy (a surgically created opening in the colon or large intestine) for a resident dependent on staff for colostomy care. This deficient practice was identified for 7 of 9 residents reviewed for ADLs (Resident #20, #76, #101, #106, #116, #354, and closed record #159), and expressed by 5 of 5 residents who attended a resident council meeting and was evidenced by the following: Refer to 677E, 686E, 689G, and 691D. [...]

Inspectors wroteBased on observation, interview and document review, it was determined that the quality assessment and assurance committee (QAPI) facility failed to ensure that the facility self-identified areas for improvement including environmental concerns, resident care related concerns and significant incidents. This deficient practice had the potential to affect all residents that resided in the facility and was evidenced by the following: Refer to F584E, F585D, F677E, F686, F689G, F924E On 11/28/23, during the initial tour of the facility, multiple surveyors observed the following: -9:40 AM: the D Unit had a strong odor of urine throughout the Unit. -11:35 AM, two surveyors observed the condition of room on the D Unit which included: D1- room and bathroom floor visibly soiled. [...]

Inspectors wroteBased on observation, interview, and review of facility documentation, it was determined that the facility failed to ensure handrails were secure and intact on 2 of 3 resident units. This deficient practice was evidenced by the following: On 11/29/23 at 11:52 AM, Surveyor #4 was on E unit and observed that outside of room [ROOM NUMBER], the handrail was not securely fastened to the wall and was slanting down on the left side. Surveyor #4 was able to physically move the handrail up and down. Surveyor #4 observed another handrail across from the E unit nurses station by the bathroom which had a broken jagged end cap. Surveyor #4 observed a handrail by the entrance door of the E unit day room which was visibly not secured to the wall. On 11/29/23 at 11:55 AM, the Registered Nurse Unit Manager (RN UM) on E wing was shown the handrails. [...]

Inspectors wroteComplaint # NJ 151052 Based on observation, interview, and review of pertinent facility provided documentation, it was determined that the facility failed to provide meals that were at acceptable temperatures for 5 of 5 residents interviewed and one test tray and ensure palatable food for 6 of 6 residents interviewed. a) On 11/28/23 at 10:27 AM, the surveyor observed Resident #355 sitting at the bedside eating breakfast. When interviewed, Resident # 355 stated the food tastes like prison food. It is bland and has no taste. On 11/29/23 at 12:39 PM, the surveyor observed Resident #355 eating his lunch. Resident # 355 stated the pork chop was a little tough. b) On 11/30/23 at 10:30 AM, Surveyor #4 conducted a resident council meeting with five residents. [...]

Inspectors wroteBased on interview and document review, the facility failed to have the Director of Nursing (DON) present for one of four Quality Assurance and Performance Improvement (QAPI) meeting as evidenced by the following: On 12/12/23 at 12:20 PM, the surveyor reviewed the quarterly QAPI sign-in sheets for the last four quarterly QAPI meetings. The second quarter sign in sheet, dated 04/03/23, was missing the attendance signature of the Director of Nursing (DON). At that time, the DON stated she may have taken that day off but handed in her report for the meeting. A review of the Facility Assessment, dated 09/01/23, revealed that the QAPI committee included the Administrator, Medical Director, Director of Nursing, Assistant Director of Nursing. [...]

Inspectors wroteComplaint # NJ 151052 Based on closed record review and review of facility documentation, it was determined that the facility failed to follow their Resident and Family Concerns and Grievances policy and procedure by failing to conduct a formal investigation of a grievance filed by a resident regarding care to determine if abuse had occurred. This deficient practice was identified for 1 of 1 residents (Resident #159) reviewed for a grievance and was evidenced as follows: A review of the closed record revealed that Resident #159 was admitted to the facility with diagnoses which included but were not limited to; fracture of the neck of the left femur, difficulty in walking, unsteadiness on feet, and muscle weakness. A review of the admission Minimum Data Set (MDS) an assessment tool used to facilitate resident care dated 12/26/21, included but was not limited to; [...]

Inspectors wroteComplaint # NJ 149879 Based on interview, record review and review of pertinent documents it was determined that the facility failed to ensure a resident was provided with a discharge summary at the time of discharge, including a documented mediation reconciliation and post discharge instructions per the facility policy. The deficient practice occurred for 1 of 1 closed records reviewed (Resident #157) for appropriate discharge and was evidenced by the following: On 12/02/23 at 8:49 AM, the surveyor reviewed the closed electronic medical record (EMR) for Resident #157 which revealed a Physician Progress Note, titled Discharge Summary, Signed by a Nurse Practitioner on 10/19/21 at 9:04 PM. The note revealed that Resident #157 was being discharged home with a family member on 10/20/21. [...]

Inspectors wroteComplaint # NJ 152112 Based on interview and document review it was determined that the facility failed to ensure that resident colostomy care was performed in accordance with physician orders for 1 of 1 closed medical records reviewed (Resident #354) for colostomy care. On 12/07/23 at 9:33 AM, the surveyor reviewed the closed electronic medical record (EMR) for Resident #354 which revealed Resident #354 had Medical Conditions which included, but were not limited to; unspecified lack of expected normal physiological development in childhood, Type 2 Diabetes Mellitus with Diabetic Neuropathy, and irritable bowel syndrome without diarrhea. The Care Plan revealed a Focus area that the resident has an alteration in gastro-intestinal status due to a colostomy, initiated 12/22/2021. [...]

Inspectors wroteBased on observation, interviews and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses, b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination and c.) maintain adequate infection control practices during food service in the kitchen. This deficient practice was observed and evidenced by the following: On 7/20/21 at 09:35 AM, the surveyor toured the kitchen in the presence of the Temporary Account Manager ([NAME]) and observed the following: 1. The surveyor washed hands at handwashing sink #1 and observed the paper towel dispenser was empty. The [NAME] stated more paper towels were coming from the stock room. [...]

Inspectors wroteBased on observation, interviews, and review of facility documents, it was determined that the facility failed to maintain a clean/homelike and sanitary environment for the residents. This deficient practice was identified in 3 rooms on 2 of 3 nursing units and was evidenced by the following: 1. During the initial tour on 07/20/2021 at 11:14 AM of E wing the following was observed: In Room E10: 1. The wall on the left was missing wallboard leaving an open area above the floor trim and a large area of stripped wallpaper. 2. Further down on the left side there was another area of stripped wallpaper and an open area with a black cable protruding from the hole. 3. The wall between the heater and the window had a large area of stripped wallpaper. 4. The wall to the right of the bed had a large area with stripped wallpaper from around the red emergency outlets to the floor trim. 5. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to apply geri sleeves (a protective sleeve that is used on the arms or legs) for a resident who was at high risk for bruising, for 1 of 1 resident reviewed for skin conditions (Resident #16). This deficient practice was evidenced by the following: According to the facility's admission Record, Resident #16 was admitted to the facility in 05/2016 with medical diagnoses which included, but not limited to; Hypertension (high blood pressure), Cerebral infarction (damage in the brain due to a loss of oxygen), hemiplegia (severe paralysis of one side of the body) and hemiparesis (mild or partial paralysis to one side of the body). [...]

Inspectors wroteBased on observations, interviews, review of clinical records and facility policies and procedures, it was determined that the facility failed to a.) provide a timely and adequate nutritional assessment and/or intervention to impede an unplanned significant weight loss and improve the nutritional parameters for 1 of 6 residents reviewed for nutrition (Resident #132). Resident #132 had a unplanned significant weight as follows: Resident #132 experienced a 14.6 pound (lb.) 6 % weight loss in one week between 6/08/21 to 6/15/21, a 10.5% weight loss of 23.9 lbs. in one month from 6/08/2021 to 7/06/21, and a 31.6 lb. weight loss in seven weeks from 6/08/21 to 7/28/21. This deficient practice was evidenced by the following: According to the facility's admission Record, Resident #132 was admitted to the facility in 6/2021 with medical diagnoses which included, but were not limited to; [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to a.) maintain an accurate accountability and reconciliation for controlled medications in 1 of 1 automated medication dispensing system storage units and b.) maintain an active Drug Enforcement Agency registration, that was not expired, to order and purchase schedule 1 and 2 controlled substances. This deficient practice was evidenced by the following: On [DATE] at 12:25 PM, the surveyor inspected the automated medication dispensing system storage unit (AMDSSU) in the presence of the Assistant Director of Nursing (ADON). The ADON ran a discrepancy report from the AMDSSU which identified that the medication count was accurate and there were no irregularities identified. [...]