All citations for Complete Care at Burlington Woods, LLC

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Complete Care at Burlington Woods, LLC

Last standard health inspection on record

June 4, 2025

Showing 1 to 25 of 37 citations

Harm to a resident
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Isolated (one or a few residents). CMS level G.
Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of December 13, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (January 5, 2024).
No harm, with potential for more than minimal harm
Install proper backup exit lighting.
Widespread (many residents). CMS level F.
Fire safety citation K-0281, Egress Deficiencies. Inspection of June 4, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (July 11, 2025).
No harm, with potential for more than minimal harm
Provide properly protected cooking facilities.
Widespread (many residents). CMS level F.
Fire safety citation K-0324, Smoke Deficiencies. Inspection of June 4, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (July 11, 2025).
No harm, with potential for more than minimal harm
Install corridor and hallway doors that block smoke.
Widespread (many residents). CMS level F.
Fire safety citation K-0363, Smoke Deficiencies. Inspection of June 4, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (July 11, 2025).
No harm, with potential for more than minimal harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Widespread (many residents). CMS level F.
Fire safety citation K-0374, Smoke Deficiencies. Inspection of June 4, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (July 11, 2025).
No harm, with potential for more than minimal harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Widespread (many residents). CMS level F.
Fire safety citation K-0521, Services Deficiencies. Inspection of June 4, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (July 11, 2025).
No harm, with potential for more than minimal harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Widespread (many residents). CMS level F.
Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of December 13, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (January 26, 2024).
No harm, with potential for more than minimal harm
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Widespread (many residents). CMS level F.
Health citation F-0867, Administration Deficiencies. Inspection of December 13, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (January 26, 2024).
No harm, with potential for more than minimal harm
Have an enclosure around a vertical opening shaft.
Widespread (many residents). CMS level F.
Fire safety citation K-0311, Smoke Deficiencies. Inspection of December 13, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (January 26, 2024).
No harm, with potential for more than minimal harm
Meet requirements for the installation and maintenance of electrical systems.
Widespread (many residents). CMS level F.
Fire safety citation K-0911, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of December 13, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (January 26, 2024).
No harm, with potential for more than minimal harm
Have power receptacles that are properly grounded.
Widespread (many residents). CMS level F.
Fire safety citation K-0912, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of December 13, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (January 26, 2024).
No harm, with potential for more than minimal harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Widespread (many residents). CMS level F.
Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of July 29, 2021. Found during a standard inspection.
The home gave a date the problem would be corrected (August 30, 2021).
No harm, with potential for more than minimal harm
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.
Pattern (more than a few residents). CMS level E.
Health citation F-0584, Resident Rights Deficiencies. Inspection of December 13, 2023. Found during a standard inspection and a complaint inspection.
The home gave a date the problem would be corrected (January 26, 2024).
No harm, with potential for more than minimal harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
Pattern (more than a few residents). CMS level E.
Health citation F-0677, Quality of Life and Care Deficiencies. Inspection of December 13, 2023. Found during a standard inspection and a complaint inspection.
The home gave a date the problem would be corrected (January 26, 2024).
No harm, with potential for more than minimal harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Pattern (more than a few residents). CMS level E.
Health citation F-0686, Quality of Life and Care Deficiencies. Inspection of December 13, 2023. Found during a standard inspection and a complaint inspection.
The home gave a date the problem would be corrected (January 26, 2024).
No harm, with potential for more than minimal harm
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Pattern (more than a few residents). CMS level E.
Health citation F-0725, Nursing and Physician Services Deficiencies. Inspection of December 13, 2023. Found during a standard inspection and a complaint inspection.
The home gave a date the problem would be corrected (January 26, 2024).
No harm, with potential for more than minimal harm
Have a plan that describes the process for conducting QAPI and QAA activities.
Pattern (more than a few residents). CMS level E.
Health citation F-0865, Administration Deficiencies. Inspection of December 13, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (January 26, 2024).
No harm, with potential for more than minimal harm
Put firmly secured handrails on each side of hallways.
Pattern (more than a few residents). CMS level E.
Health citation F-0924, Environmental Deficiencies. Inspection of December 13, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (January 26, 2024).
No harm, with potential for more than minimal harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0211, Egress Deficiencies. Inspection of July 29, 2021. Found during a standard inspection.
The home gave a date the problem would be corrected (August 30, 2021).
No harm, with potential for more than minimal harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0222, Egress Deficiencies. Inspection of July 29, 2021. Found during a standard inspection.
The home gave a date the problem would be corrected (August 30, 2021).
No harm, with potential for more than minimal harm
Have exits that are accessible at all times.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0271, Egress Deficiencies. Inspection of July 29, 2021. Found during a standard inspection.
The home gave a date the problem would be corrected (August 30, 2021).
No harm, with potential for more than minimal harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0374, Smoke Deficiencies. Inspection of July 29, 2021. Found during a standard inspection.
The home gave a date the problem would be corrected (August 30, 2021).
No harm, with potential for more than minimal harm
Have proper medical gas storage and administration areas.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0923, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of July 29, 2021. Found during a standard inspection.
The home gave a date the problem would be corrected (August 30, 2021).
No harm, with potential for more than minimal harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Isolated (one or a few residents). CMS level D.
Health citation F-0684, Quality of Life and Care Deficiencies. Inspection of January 27, 2026. Found during a complaint inspection.
The home gave a date the problem would be corrected (February 13, 2026).
No harm, with potential for more than minimal harm
Ensure services provided by the nursing facility meet professional standards of quality.
Isolated (one or a few residents). CMS level D.
Health citation F-0658, Resident Assessment and Care Planning Deficiencies. Inspection of June 4, 2025. Found during a standard inspection and a complaint inspection.
The home gave a date the problem would be corrected (July 11, 2025).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.