Average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Orange Park during CMS and state inspections, most recent first.
Kitchen observations found two FSWs with facial hair not wearing beard guards, despite facility policy requiring them. Surveyors also found an out-of-date prepared salad and fresh basil with soft brown areas in the walk-in refrigerator, while the DD acknowledged the items were no longer acceptable. The findings showed improper food labeling, dating, and handling practices.
A resident with a history of stroke and diabetes was not seen by a physician at the required intervals after admission, with only one late physician entry documented and all other visits conducted by a Family Nurse Practitioner, contrary to regulatory requirements.
Call bell system was not functioning properly in a resident room. A resident’s call bell cord was missing for a couple of days, the annunciator panel did not show the missing cord, the visual indicator bulb was not working, and the call bell did not activate when tested by the MD. The MD confirmed the observations.
Failure to Maintain Clean and Sanitary Environment: Surveyors observed a hole in a wall, peeling molding and tiles, a scissors with soiled adhesive tape on a windowsill, and geriatric recliners, a wheelchair, and a mechanical lift stored in a shower room. A broken toilet paper holder was also observed, with toilet paper placed on top of the toilet tank.
A resident admitted with left foot drop was observed using an orthotic on the left leg while seated in a wheelchair, but the active order summary did not include a physician order for the device and the care plan did not reflect its use. The UM and DON both acknowledged that a physician order should have been present, and the facility could not provide a policy for orthotic orders.
The facility failed to ensure that primary physicians signed and dated monthly orders for 19 residents and that NPs accurately dated progress notes. Interviews revealed a lack of awareness and understanding of the requirements for timely physician visits and documentation, contributing to widespread deficiencies.
The facility failed to ensure that physicians conducted face-to-face visits and wrote progress notes at least once every sixty days for 21 of 36 residents reviewed. Multiple residents had no documented evidence of physician visits within the required timeframe, with progress notes often completed by APNs or NPs instead of the physicians themselves.
The facility failed to assist a resident with bilateral hand contractures in opening their mail, despite the resident's expressed need for help. The resident had several unopened mails and no staff had offered assistance, contrary to the facility's policy.
The facility failed to submit MDS assessments within the required 14-day period for four residents, with delays ranging from a few days to several weeks. The MDS Coordinator acknowledged the late submissions, and the facility management was notified of these findings.
The facility failed to accurately code the MDS for a resident who left AMA, and multiple residents' MDS assessments lacked proper documentation of mood and pressure ulcer evaluations. Staff admitted to not following ARD guidelines for these assessments.
The facility failed to accurately administer and document medication for two residents and did not follow a physician's order for pain management for another resident. One resident received an incorrect dose of Vimpat due to improper measuring, another did not receive their prescribed Potassium Chloride due to unavailability, and a third resident's pain levels were not appropriately categorized, leading to incorrect medication administration.
The facility failed to complete pain assessments according to policy for two residents receiving Methadone for pain management. Despite care plans and facility policy requiring regular pain assessments, staff only conducted and documented these assessments infrequently, leading to a deficiency in pain management.
The facility failed to provide pharmaceutical services by not ensuring the accurate administration of Midodrine and the availability of medications as ordered by the physician. A resident did not receive Midodrine, Pantoprazole, and Psyllium on multiple occasions due to unavailability, and there was no follow-up with the physician or pharmacy. The facility's policies for administering medications and handling unavailable medications were not followed.
The facility failed to maintain proper kitchen sanitation and food storage practices, including staff wearing prohibited jewelry, frost build-up in the walk-in freezer, and debris build-up in the walk-in refrigerator, contrary to facility policies.
Food Handling and Sanitation Deficiencies Observed in Kitchen
Penalty
Summary
The facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. During observation of the kitchen with the Dietary Director present, a Food Service Worker had facial hair and was not wearing a beard guard, and the Dietary Director stated the worker should have been wearing one. A second Food Service Worker was also observed with facial hair and no beard guard, and the Dietary Director again stated the worker should have had a beard guard. In the walk-in refrigerator, surveyors observed a prepared salad labeled with a prep date of 9/15 and an expiration date of 9/17, and the Dietary Director stated it was out of date. Surveyors also observed a plastic bag of fresh basil dated 9/10 with soft brown areas on several leaves, and the Dietary Director stated the basil looked a little soft and would be tossed. Facility policy required dietary staff with facial hair to wear an appropriate beard guard, required food items to be properly labeled and dated, and directed that herbs that are slimy or moldy be discarded.
Failure to Ensure Timely Physician Visits for Resident
Penalty
Summary
The facility failed to ensure that a resident was seen by a physician at the required intervals following admission, as mandated by regulation. Specifically, the resident, who was admitted in March 2025 and had diagnoses including sequelae of cerebral infarction and type 2 diabetes mellitus, did not have documented physician visits at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. The only physician entry found was a late entry created in April 2025 but dated for March 30, 2025, with no other documented physician visits during the required period. Instead, the resident was seen multiple times by a Family Nurse Practitioner, but these visits do not fulfill the regulatory requirement for physician face-to-face visits. Interviews with facility leadership confirmed that the attending physician was noncompliant with the required visit schedule prior to May 2025, and there was no further documentation of physician visits for the resident during the period in question. The facility's own policy also requires physician visits at the specified intervals, which were not met in this case.
Call Bell System Not Functioning Properly
Penalty
Summary
The facility failed to ensure that the resident call bell system was properly functioning in all areas. During observations with the Regional Maintenance Director and Maintenance Director, the call bell cord was missing from a resident room while the resident was in bed, and the resident stated the cord had been missing for a couple of days. There was no indication at the call bell annunciator panel that the cord was missing, the visual notification bulb at the panel was not functioning when the call bell was tested, and the call bell did not activate when tested by the Maintenance Director for the window bed in the same room. The Maintenance Director confirmed these observations at the time.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in 2 of 3 units, including the first and second floors, based on surveyor observations. During the initial tour, a hole was observed in the wall behind the door of one room, and in another room the molding at the bottom of the wall was peeling off with two tiles peeling at the edges. In a separate room, a scissors with soiled adhesive surgical tape attached to it was observed on the windowsill, and the same item was still observed there on a later date. In the shower room outside another room, geriatric recliners, a wheelchair, and a mechanical lift were stored in the shower room, and within the bathroom area the surveyor observed a broken toilet paper holder with toilet paper placed on top of the toilet tank.
Missing Physician Order for Orthotic Device
Penalty
Summary
The facility failed to obtain a physician's order for an orthotic device for Resident #80, who was admitted with diagnoses including left foot drop and whose MDS reflected impaired use of one lower extremity. During observation, the resident was seen in a wheelchair with an orthotic device on the left leg. Review of the active order summary did not show an order for the orthotic device, and the current care plan did not reflect its use. The Unit Manager stated that there should be a physician order for an orthotic and acknowledged that none was present, and the DON also stated that there should be a physician order for an orthotic. The facility was unable to provide a policy regarding having a physician order for an orthotic.
Failure to Ensure Timely Physician Signatures and Accurate Documentation
Penalty
Summary
The facility failed to ensure that the residents' primary physicians signed and dated monthly physician orders for residents under their care. This deficiency was identified for 19 of 35 residents reviewed. For instance, Resident #53's medical record revealed that the primary physician had not signed monthly orders for December 2023, February 2024, March 2024, and April 2024. Similarly, Resident #77's primary physician had not signed monthly orders for December 2023 and February 2024. These lapses were consistent across multiple residents, indicating a systemic issue in the facility's process for ensuring timely physician signatures on monthly orders. Additionally, the facility failed to ensure that the nurse practitioners (NPs) accurately dated physician progress notes (PPNs) during their visits. For example, Resident #171's electronic medical record showed several PPNs with late entry designations, indicating that the notes were not written on the effective date. This issue was also observed for Resident #460, whose PPN with an effective date of 4/23/2024 was created on 5/2/2024. The practice of backdating PPNs was noted for several other residents, further highlighting the facility's failure to maintain accurate and timely medical documentation. Interviews with facility staff, including NPs and the Licensed Nursing Home Administrator (LNHA), revealed a lack of awareness and understanding of the requirements for timely physician visits and documentation. The LNHA and other administrative staff acknowledged that physician visits had not been completed timely or sequenced with the NPs, and there was confusion about the frequency and timing of required signatures. This lack of clarity and oversight contributed to the widespread deficiencies in the facility's medical documentation practices.
Failure to Ensure Timely Physician Visits and Progress Notes
Penalty
Summary
The facility failed to ensure that the responsible physician supervising the care of residents conducted face-to-face visits and wrote progress notes at least once every sixty days. This deficiency was identified for 21 of 36 residents reviewed for physician visits. The surveyor's observations and record reviews revealed that multiple residents had not been seen by their attending physician within the required timeframe, with progress notes often completed by Advanced Practice Nurses (APNs) or Nurse Practitioners (NPs) instead of the physicians themselves. For instance, Resident #77, who was admitted with diagnoses including right knee contracture and pyogenic arthritis, had no documented evidence of a physician visit for several months, with all progress notes completed by an APN. Similarly, Resident #105, who had diagnoses including anemia, asthma, and major depressive disorder, had no physician progress notes for several months, with all notes completed by an NP. The NP confirmed that she completed electronic progress notes monthly but was unsure of the physician's visit schedule. The facility's Licensed Nursing Home Administrator (LNHA) and other staff acknowledged that physician visits had not been completed timely and that physicians were reeducated on the requirements. Other residents, such as Resident #30, Resident #172, and Resident #183, also lacked documented evidence of physician visits within the required sixty-day period. The facility's policy stated that attending physicians must visit residents at least once every thirty days for the first ninety days following admission and then at least every sixty days thereafter. Despite this policy, the survey revealed significant gaps in physician visits and progress notes, indicating a systemic issue in ensuring compliance with state and federal regulations for physician oversight in resident care.
Failure to Assist Resident with Mail
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident with bilateral hand contractures by not assisting in opening the resident's mail. The surveyor observed the resident in bed with hand splints and several unopened mails on the nightstand and bedside table. The resident expressed a desire for assistance in opening the mail, stating that no staff had offered to help. The resident's medical history included contractures in both hands, generalized osteoarthritis, major depressive disorder, and dysphagia, with a moderate cognitive impairment indicated by a BIMS score of 10 out of 15. Interviews with the unit manager and the facility's Director of Recreation and Volunteers revealed a lack of awareness and responsibility regarding mail delivery and assistance. The unit manager was unaware of who delivered the mail, while the Director of Recreation and Volunteers stated that activity staff were responsible for mail distribution and should offer assistance if needed. The facility's policy indicated that residents should be given the choice to open their mail privately or receive assistance, but this was not followed in the case of the resident.
Failure to Timely Submit MDS Assessments
Penalty
Summary
The facility failed to complete and submit the Minimum Data Set (MDS) assessments electronically within the required 14-day period as mandated by the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. This deficiency was identified for four residents. For Resident #18, the Annual MDS (AnMDS) and Quarterly MDS (QMDS) assessments were submitted late on multiple occasions, with delays ranging from a few days to several weeks. Similarly, Resident #22 had multiple instances of late submissions for AnMDS, Significant Change MDS (ScMDS), and QMDS assessments, with delays also ranging from a few days to several weeks. Resident #57's Admission MDS (AdMDS) was submitted 13 days late, and Resident #64's AnMDS was submitted five days late. The MDS Coordinator/Registered Nurse (MDSC/RN) acknowledged that the MDS assessments were submitted and accepted late, despite being aware of the RAI Manual requirements. The surveyor's review of the Final Validation Report confirmed that the assessments for the four residents were completed more than 14 days after the Assessment Reference Date (ARD). The facility management, including the Licensed Nursing Home Administrator and Director of Nursing, were notified of these findings and concerns during the survey team's visit.
MDS Coding and Assessment Deficiencies
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for Resident #207, who left the facility against medical advice (AMA). The discharge MDS was incorrectly coded as a discharge to an acute hospital. The error was attributed to the facility social worker who entered the information incorrectly. The facility policy requires that any person completing any portion of the MDS assessment must certify the accuracy of that portion, which was not adhered to in this case. The Regional Clinical Nurse acknowledged the error during an interview with the surveyor team. Resident #57's Quarterly MDS did not include documentation of a PHQ-2 to 9 assessment interview on the Assessment Reference Date (ARD). Similarly, Resident #64's Quarterly MDS lacked a PHQ-9-OV interview on the ARD. Additionally, Resident #37's Admission MDS had a PHQ-2 to 9 evaluation done five days before the ARD, and Resident #18's Quarterly MDS had a PHQ-2 to 9 interview done twenty-five days before the ARD. The facility's social worker and MDS Coordinator/Registered Nurse stated that they did not follow the ARD for these assessments, contrary to the guidelines. Resident #22's Annual MDS did not reflect a stage two pressure ulcer on the left buttock, despite weekly skin reviews documenting the ulcer. The MDS Coordinator/Registered Nurse admitted to missing this information on the MDS. The surveyor team discussed these concerns with the facility's Regional Clinical Nurse, Licensed Nursing Home Administrator, and Assistant Administrator, who acknowledged the errors but provided no further information.
Medication Administration and Pain Management Deficiencies
Penalty
Summary
The facility failed to follow acceptable standards of clinical practice for accurately administering and documenting medication for two residents. One resident was given an incorrect dose of Vimpat due to the LPN using an inappropriate measuring device. The LPN initially used a medication dose cup that did not have a marking for the exact dose required, leading to an inaccurate measurement. The correct dose was only administered after the surveyor intervened and the LPN used a calibrated dose syringe. The resident had severe cognitive impairment and a history of seizure disorders, making accurate medication administration critical. Another resident did not receive their prescribed Potassium Chloride Oral packet because it was unavailable. The LPN documented the medication as not given but did not follow up adequately to ensure the medication was obtained. The facility's pharmacy confirmed that the medication was not delivered and that multiple attempts to notify the facility were unsuccessful. Despite this, the medication was documented as administered on several occasions, indicating a failure in both communication and documentation processes. The facility also failed to follow a physician's order for pain management for a resident with multiple diagnoses, including cellulitis and peripheral vascular disease. The resident's pain levels were not appropriately categorized, leading to the administration of medication that did not align with the prescribed treatment for varying pain levels. The LPN and Unit Manager had differing interpretations of what constituted mild pain, and the facility's policy did not provide clear guidelines. This inconsistency resulted in the resident receiving medication for pain levels that were not accurately assessed.
Failure to Complete Pain Assessments as per Policy
Penalty
Summary
The facility failed to ensure that pain level assessments were completed according to facility policy for two residents, Resident #77 and Resident #92, who were reviewed for pain management. Resident #92, who was admitted with diagnoses including pain in both feet and opioid dependence, was receiving Methadone daily for pain management. However, the electronic medication administration records (eMAR) for March, April, and May 2024 did not show any documentation of pain assessments, despite the resident receiving Methadone every day. The care plan for Resident #92 indicated that pain assessments should be completed on admission and per facility policy, but this was not adhered to. Interviews with staff revealed a misunderstanding of the policy, with LPN#7 stating that pain levels should only be assessed if the resident appears in pain, contrary to the facility's policy requiring regular pain assessments. Similarly, Resident #77, who experienced leg pain and received Methadone three times daily, also did not have documented pain assessments. The resident's medical record indicated intact cognition and diagnoses of contracture of the right knee and arthritis. Despite the care plan stating that pain assessments should be completed on admission and per facility policy, staff interviews revealed that pain assessments were only done quarterly and not documented regularly. The facility policy required pain assessments at least each shift, but this was not followed. The Licensed Nursing Home Administrator and the Regional Clinical Nurse acknowledged the issue but did not provide further information on corrective actions.
Failure to Administer Medications and Ensure Availability
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring the accurate administration of Midodrine and the availability of medications as ordered by the physician. This deficiency was identified for one resident who had a physician's order for Midodrine to be administered every 8 hours for low blood pressure, with specific instructions to hold the medication if the systolic blood pressure was greater than 130. However, the medication was not administered on multiple occasions due to it not being available, and there was no documentation of follow-up with the physician or pharmacy to address the unavailability of the medication. Additionally, the Midodrine was incorrectly held when the resident's blood pressure was 98/57, which was below the threshold specified in the physician's order. The resident also had orders for Pantoprazole and Psyllium, which were not administered on several occasions due to the medications not being available, and again, there was no documentation of follow-up with the physician or pharmacy to resolve the issue. The facility's policies for administering medications and handling unavailable medications were not followed, as evidenced by the lack of documentation and follow-up actions by the nursing staff. The facility's consultant pharmacist confirmed that there should have been follow-up when medications were not available and that the nurses needed to read and follow the physician's orders accurately.
Improper Kitchen Sanitation and Food Storage Practices
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices and store potentially hazardous foods correctly, which could lead to foodborne illness. During a kitchen tour, the surveyor observed the Certified Dietary Manager (CDM) and Chef wearing earrings that hung more than one inch from their earlobes, which is prohibited by the facility's Uniform Policy. Additionally, the walk-in freezer had frost build-up on one of the two fans, and multiple boxed items were stacked above 18 inches from the ceiling, contrary to the facility's Receivable and Storage Policy. The walk-in refrigerator also had a blackish-colored debris build-up on two fans, which the CDM stated was the responsibility of the maintenance department to clean. The surveyor reviewed multiple facility policies, including the Uniform Policy, Receivable and Storage Policy, and Reporting Equipment/Maintenance Needs Policy, which outlined the proper procedures for kitchen sanitation and food storage. Despite these policies, the facility did not adhere to them, as evidenced by the observations made during the kitchen tour. The Licensed Nursing Home Administrator (LNHA), Regional Clinical Nurse (RCN), and Assistant LNHA (ALNHA) were informed of these concerns, and the RCN stated they would investigate the kitchen issues further.
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What surveyors actually found near you
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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.
Illustrative
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Nursing homes near East Orange
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grove Park Healthcare And Rehabilitation Center | 0.4 mi | ★★★★★ | 11 | 1 |
| Park Crescent Healthcare & Rehabilitation Center | 0.7 mi | ★★★★★ | 12 | 0 |
| Job Haines Home For Aged People | 1.4 mi | ★★★★★ | 0 | 0 |
| Sinai Post-acute Nursing & Rehab Center | 1.4 mi | ★★★★★ | 1 | 0 |
| Broadway House For Continuing Care | 1.6 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.