Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Marcella during CMS and state inspections, most recent first.
A resident with impaired cognition, poor safety awareness, and elopement/fall risk was allowed to leave the elevator area and enter a courtyard without documented supervision. The resident later had an unwitnessed fall with facial injuries and reported dizziness. Surveyors also found that another resident had access to the elevator code and could deactivate the alarm system, allowing the at-risk resident to ride the elevator without staff escort.
A resident receiving oxygen therapy had nasal cannula tubing and later nebulizer mask/tubing observed exposed to air rather than stored in a bag when not in use. The equipment was labeled with an earlier date, and the IP, an LPN, and the DON stated respiratory equipment should be bagged when not in use; the facility policy also required weekly changes and storage in a plastic bag.
Late Medication Administration: Two residents had prescribed medications administered outside scheduled times, including pain medication, gabapentin, anticoagulant therapy, and inhaled asthma treatment. One resident with chronic pain and neuropathy had repeated late doses of Morphine ER and gabapentin, while another resident with a-fib, neuropathy, and asthma had late doses of gabapentin, dabigatran, and Advair. Staff interviews confirmed the facility’s practice allowed medications to be given within about one hour of the scheduled time, and the DON stated late doses required physician notification and an order.
Staff failed to consistently document ADL care and services provided to four residents with significant care needs, resulting in multiple missing entries for eating, meal intake, turning and repositioning, personal hygiene, toileting hygiene, and transfers. Interviews confirmed that CNAs were responsible for this documentation, and the DON acknowledged gaps in the records despite facility policies requiring complete documentation.
The facility failed to perform skin scrapings to confirm scabies for two residents, leading to a deficiency in infection control. Despite presenting symptoms and receiving treatment, no diagnostic confirmation was obtained, contrary to facility policy. Interviews with staff and the physician revealed a lack of adherence to procedures, resulting in unconfirmed scabies diagnoses.
Unsafe Supervision and Door Code Access Allowed an Elopement-Risk Resident to Fall
Penalty
Summary
The facility failed to maintain a safe environment and provide adequate supervision for a resident who had poor safety awareness, impaired cognition, a history of falls, and was identified as an elopement and fall risk. The resident’s records showed diagnoses including congestive heart failure, muscle weakness, schizophrenia, and difficulty walking. The resident’s MDS indicated moderately impaired cognition and the need for supervision or touching assistance with walking. The resident’s elopement assessment showed a high risk for elopement, a history of elopement attempt, and behaviors including expressing a desire to leave, wandering, hovering at exits, and being observed near the elevator and redirected by staff. The resident’s care plan identified the resident as an elopement risk/wanderer with impaired safety awareness, with interventions including a Wander Guard, diversions, and identification of wandering patterns. The resident also had care plan interventions related to diuretic therapy and antidepressant use, including monitoring for postural hypotension, dizziness, falls, and adverse reactions. The facility’s own policy stated that residents at risk for elopement would receive adequate supervision to prevent accidents, and the Wander Guard instructions stated that the system was intended to lock doors when a monitored resident approached and that the code should only be given to authorized staff members. On the day of the incident, the resident was observed leaving the elevator alone and was allowed access into the courtyard by the LNHA. The resident was later found seated on a courtyard bench with visible facial injuries and reported feeling dizzy and falling forward onto the face. Staff statements indicated the resident was found in the courtyard after yelling for help, and the resident was sent to the hospital for further evaluation because of the unwitnessed fall with head impact and anticoagulant use. The facility did not provide evidence that the resident was supervised while in the courtyard. In addition, another resident had been given the elevator code and was able to deactivate the alarm system, allowing the elopement-risk resident to travel on the elevator without staff escort.
Respiratory Equipment Left Exposed to Air
Penalty
Summary
The facility failed to ensure infection control practices were followed for the handling and storage of respiratory equipment for one resident receiving respiratory care. Resident #92 was admitted with a history of atherosclerotic heart disease of the native coronary artery without angina pectoris and had an active physician order for oxygen at 2 liters via nasal cannula as needed for shortness of breath, wheezing, or if SP02 fell below 93%. During rounds on 7/16/2025, the surveyor observed the resident in bed with the nasal cannula labeled 7/13/2025 coiled directly on top of the oxygen concentrator, not in a bag and exposed to air. On 7/17/2025, the surveyor observed the oxygen tubing now bagged, but it remained labeled with the date 7/13/2025, indicating it had been previously exposed and potentially reused. On 7/18/2025, the surveyor observed the resident's nebulizer mask and tubing exposed and open to air on top of a stuffed animal on the windowsill, not in a bag. The Infection Preventionist, an LPN, and the DON each stated that respiratory equipment should be kept in a bag when not in use, and the facility policy titled Oxygen Administration stated that oxygen tubing and mask/cannula should be changed weekly and kept covered in a plastic bag when not in use.
Late Medication Administration
Penalty
Summary
The facility failed to administer medications within the scheduled medication administration times for 2 residents reviewed for significant medication errors. One resident with chronic pain, physical disability, multiple wounds, and neuropathy was prescribed Morphine Sulfate ER 15 mg daily and gabapentin 300 mg at 9:00 AM and 1:00 PM, but the medication audit showed doses given late on multiple dates, including Morphine Sulfate ER at 10:35 AM, 11:32 AM, and 10:50 AM, and gabapentin doses given at times such as 10:32 AM, 3:17 PM, 2:12 PM, 2:27 PM, 2:13 PM, 11:32 AM, 2:20 PM, 10:51 AM, and 2:35 PM. During observation, the resident was in bed and declined interview due to pain, and facial grimacing was noted. An LPN/UM stated that nurses may not document medications as administered at the administration time due to various distractions, and the DON stated medications could be given one hour before or one hour after the scheduled time. A second resident with paroxysmal atrial fibrillation, neuropathy, and asthma was prescribed gabapentin 300 mg three times daily, metoprolol succinate ER 25 mg daily, dabigatran etexilate mesylate 150 mg twice daily, and Advair Diskus 500/50 mcg twice daily. The medication audit showed gabapentin given at 3:10 PM and 3:09 PM for a 2:00 PM dose, dabigatran given at 11:30 PM, 2:03 AM, and 10:22 PM for 9:00 PM doses, and Advair given at 10:55 PM and 10:10 PM for 9:00 PM doses. An LPN stated medications should be given within one hour before or after the scheduled time, and the DON stated late medications required physician notification and an order. The facility policy stated medications are to be administered in accordance with the six rights, including the right time, and that medications should be administered within 60 minutes prior to or after the scheduled time unless otherwise ordered.
Failure to Document ADL Care and Services Provided
Penalty
Summary
Facility staff failed to consistently document the Activities of Daily Living (ADL) status and care provided to residents, as well as to follow the Certified Nursing Assistant (CNA) job description and the facility's ADL policy. This deficiency was identified for four residents, each with significant medical needs such as malnutrition, dementia, muscle weakness, and impaired mobility. For these residents, there were multiple instances where documentation was missing in the Documentation Survey Report (DSR) and progress notes, specifically regarding eating, meal intake, turning and repositioning, personal hygiene, toileting hygiene, and transfers. For one resident with moderate cognitive impairment, malnutrition, and a history of unplanned weight loss, there was no documented evidence of ADL care or refusals on numerous dates and shifts, including missing records for eating, meal intake, turning and repositioning, and personal hygiene. Another resident with muscle wasting and moderate malnutrition had no documentation of meal intake or refusals at several mealtimes throughout the month. A third resident, who was severely cognitively impaired and dependent on staff for eating and personal hygiene, also had multiple gaps in documentation for meal intake, ADL care, and turning and repositioning. The fourth resident, with hemiplegia and a need for assistance with personal care, had missing documentation for personal hygiene, toileting hygiene, and transfers on several shifts. Interviews with staff confirmed that CNAs were responsible for documenting ADL care in the electronic system and that documentation was emphasized during orientation. The Director of Nursing acknowledged the presence of blank spaces in the documentation and reiterated the importance of accurate record-keeping for accountability. Review of facility policies and CNA job descriptions further confirmed the expectation for complete and timely documentation of ADL care provided to residents.
Failure to Confirm Scabies Diagnosis with Skin Scraping
Penalty
Summary
The facility failed to perform skin scrapings to confirm the presence of scabies for two residents, leading to a deficiency in infection prevention and control. Resident #1 presented with a rash across multiple areas of the body, and a physician ordered Ivermectin for scabies treatment without confirming the diagnosis through a skin scraping. Similarly, Resident #4 was prescribed Permetherin Cream following a dermatology appointment, but no skin scraping was performed to confirm the scabies diagnosis. Both residents received treatment for scabies without the necessary diagnostic confirmation. Interviews with facility staff revealed a lack of adherence to the facility's policy on scabies identification and treatment, which requires skin scrapings for microscopic identification. The Director of Nursing (DON) confirmed that no skin scrapings were conducted for the residents in question, despite the facility's policy mandating such procedures. The Unit Manager also acknowledged that no skin scrapings were performed and that the dermatology office had not conducted one for Resident #4. The treating physician admitted that although Ivermectin and Permetherin are commonly used for scabies treatment, no positive skin scrapings were reported, and the diagnosis was not confirmed. The facility's policy on scabies identification, treatment, and environmental cleaning was not followed, as evidenced by the lack of skin scrapings and the absence of confirmed scabies cases. The DON stated that if a positive skin scraping result had been obtained, the facility would have notified the Department of Health, indicating a gap in the facility's infection control practices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Burlington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Burlington Woods, Llc | 0.6 mi | ★★★★★ | 1 | 0 |
| Masonic Village At Burlington | 1.9 mi | ★★★★★ | 2 | 0 |
| Bristol Health & Rehab Center | 4.6 mi | ★★★★★ | 0 | 0 |
| Mount Holly Rehabilitation & Healthcare Center | 4.7 mi | ★★★★★ | 0 | 0 |
| Careone At Moorestown | 5.8 mi | ★★★★★ | 1 | 0 |
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