Complete Care at Burlington Woods, LLC
115 Sunset Road, Burlington, NJ 08016 · Burlington County · 215 certified beds · avg 181 residents/day · certified since Dec 1, 1976
Part of chain: COMPLETE CARE (85 facilities, chain avg rating 3.1★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Dec 13, 2023 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 5, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (23)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jan 27, 2026 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jun 4, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Jun 4, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jun 4, 2025 | D · Potential for harm, one-off | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Dec 13, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Dec 13, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Dec 13, 2023 | F · Potential for harm, facility-wide | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Dec 13, 2023 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Dec 13, 2023 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Dec 13, 2023 | E · Potential for harm, repeated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Dec 13, 2023 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Dec 13, 2023 | E · Potential for harm, repeated | The facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. |
| Dec 13, 2023 | E · Potential for harm, repeated | The facility did not have firmly secured handrails on both sides of its hallways. |
| Dec 13, 2023 | D · Potential for harm, one-off | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint |
| Dec 13, 2023 | D · Potential for harm, one-off | The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. |
| Dec 13, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Dec 13, 2023 | D · Potential for harm, one-off | When a resident had a planned discharge, the facility did not make sure the necessary information was communicated to the resident and to the doctors or facility taking over their care. · from a complaint |
| Dec 13, 2023 | D · Potential for harm, one-off | The facility did not provide proper care for residents with a colostomy, urostomy, or ileostomy — surgical openings in the abdomen that let waste leave the body into a pouch. These require regular, skilled attention to stay clean and healthy. · from a complaint |
| Jul 29, 2021 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 29, 2021 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Jul 29, 2021 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jul 29, 2021 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Jul 29, 2021 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (11 → 3).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 5 | 0 | F |
| 2023 | 14 | 1 | G ▲ |
| 2025 | 3 | 0 | D |
| 2026 | 1 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $63,469.
| Date | Type | Amount / length |
|---|---|---|
| Dec 13, 2023 | Fine | $63,469 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | New Jersey avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.48 | 3.88 | 3.95 | bottom 38% in New Jersey; bottom 36% in the U.S. |
| Registered Nurse hours | 0.40 | 0.67 | 0.69 | bottom 23% in New Jersey; bottom 23% in the U.S. |
| Weekend total nurse staffing | 3.20 | 3.53 | 3.50 | bottom 41% in New Jersey; bottom 42% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.36 | 0.50 | 0.48 | bottom 44% in New Jersey; bottom 45% in the U.S. |
| Total nursing staff turnover (%) | 41.7 | 39.7 | 45.8 | bottom 44% in New Jersey; top 41% in the U.S. |
| RN turnover (%) | 37.5 | 37.7 | 42.9 | bottom 49% in New Jersey; top 42% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.56, RN 0.41, weekend 3.27. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 3/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| PC NJ1 Opcos LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 07/01/2021 |
| PC Wta Opco Holdco LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 07/01/2021 |
| SMS 2021 Trust | Organization | 5% or Greater Indirect Ownership Interest | — | 07/01/2021 |
| Stein, Shalom | Individual | Indirect Ownership Interest | NOT APPLICABLE | 07/01/2021 |
| Aurora Guardian Holdco II Co-Borrower, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2021 |
| Aurora Guardian Holdco II Mezz Borrower, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2021 |
| Aurora Guardian Holdco II, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2021 |
| Aurora Guardian II Realty, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2021 |
| Aurora Guardian Partners II LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2021 |
| Bevans, Sakia | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2021 |
| Burlington Woods Realty, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2021 |
| Goldman, Eliyahu | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2021 |
| Goldman, Eliyahu | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2021 |
| Hoch, Robert | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2021 |
| Hoch, Robert | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2021 |
| J & R Family Investments, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2021 |
| L Friedman 2018 Family Trust | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2021 |
| L Friedman Family Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2021 |
| Landau Family Investment Trust | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2021 |
| M Friedman 2018 Family Trust | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2021 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "Where do you post your daily staffing numbers, and can I see today's?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How does your quality committee work, and can you give an example of a problem it recently identified and fixed?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Complete Care at Marcella | 0.6 mi | Burlington, NJ | ★★★★★ | 4/5 | |
| Masonic Village at Burlington | 1.3 mi | Burlington, NJ | ★★☆☆☆ | 1/5 | abuseSFF |
| Bristol Health & Rehab Center | 4.1 mi | Bristol, PA | ★☆☆☆☆ | 1/5 | |
| Mount Holly Rehabilitation & Healthcare Center | 5.1 mi | Lumberton, NJ | ★☆☆☆☆ | 1/5 | abuse |
| Careone at Moorestown | 6.4 mi | Moorestown, NJ | ★★★☆☆ | 3/5 | |
| Total Rehab Moorestown | 6.8 mi | Moorestown, NJ | ★★★☆☆ | 2/5 | |
| Willowbrooke Court Skilled Care at Evergreens | 7.0 mi | Moorestown, NJ | ★★★★★ | 5/5 | |
| Juniper Village at Bucks County Rehab and SKD Care | 7.3 mi | Bensalem, PA | ★★★★★ | 4/5 | |
| Cambridge Rehabilitation and Healthcare Center | 7.4 mi | Moorestown, NJ | ★★★☆☆ | 2/5 | |
| River's Edge Rehabilitation & Healthcare Center | 7.4 mi | Philadelphia, PA | ★★★★☆ | 3/5 | |
| Wynwood Rehabilitation and Healthcare Center | 8.2 mi | Cinnaminson, NJ | ★★☆☆☆ | 1/5 | |
| Statesman Health & Rehabilitation Center | 8.3 mi | Levittown, PA | ★★★★☆ | 3/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 315050.