Inspection Reports for
Complete Care At Orange Park
140 Park Ave, East Orange, NJ, 07017
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
12.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
135% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
84% occupied
Based on a January 2023 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Notice
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice outlines the types of information covered, reasons for use and disclosure of health information, individuals' rights regarding their health information, legal duties of NJDHSS, and contact information for privacy concerns.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 24, 2025
Visit Reason
The inspection was conducted based on Complaint #425693 to investigate whether the facility ensured residents were seen by a physician at required intervals.
Complaint Details
Complaint #425693 was substantiated based on interviews, record reviews, and facility documentation showing noncompliance with physician visit requirements for Resident #167.
Findings
The facility failed to ensure that Resident #167 was seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter, as required by facility policy and regulations.
Deficiencies (1)
Failure to ensure residents were seen by a physician at required intervals, specifically Resident #167 was not seen by a physician as required.
Report Facts
Resident reviewed for physician visits: 2
Dates of Nurse Practitioner visits: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Clinical Director | Interviewed and provided information about physician visit requirements and compliance. | |
| Director of Nursing | Confirmed lack of documentation of physician visits for Resident #167. |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Sep 18, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, environment, physician visits, food safety, and call system functionality at Complete Care at Orange Park.
Complaint Details
Complaint #425693 involved failure to ensure residents were seen by a physician at required intervals. The complaint was substantiated based on record review and interviews showing noncompliance with physician visit requirements for Resident #167.
Findings
The facility was found deficient in maintaining a clean and homelike environment, obtaining physician orders for orthotic devices, ensuring timely physician visits, handling and storing food safely, and maintaining a working resident call bell system. All deficiencies were cited with minimal harm or potential for harm to residents.
Deficiencies (5)
Failed to maintain a clean and sanitary environment for 2 of 3 units, including holes in walls, peeling molding and tiles, and soiled surgical scissors left on windowsills.
Failed to obtain a Physician's Order for an orthotic device for 1 of 2 residents reviewed for positioning and mobility.
Failed to ensure residents were seen by a physician at required intervals, specifically 1 of 2 residents was not seen by a physician as required.
Failed to handle potentially hazardous food and maintain sanitation, including staff not wearing beard guards and expired or spoiled food items found in the kitchen.
Failed to ensure the resident call bell system was properly functioning in all areas; call bell cords missing and annunciator panel bulbs not working.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 3
Dates of physician visits: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Acknowledged findings related to scissors in resident room and physician visit compliance |
| Regional Director of Nursing | Regional Director of Nursing | Interviewed regarding environment deficiencies and physician visit compliance |
| Unit Manager | Unit Manager | Acknowledged lack of physician order for orthotic device |
| Regional Clinical Director | Regional Clinical Director | Interviewed regarding physician visit compliance and facility policy |
| Dietary Director | Dietary Director | Present during food safety observations and acknowledged staff not wearing beard guards |
| Maintenance Director | Maintenance Director | Confirmed observations of non-functioning call bell system |
| Regional Maintenance Director | Regional Maintenance Director | Present during call bell system observations |
Inspection Report
Routine
Deficiencies: 2
Date: Jul 15, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control practices, specifically related to the dating and changing of respiratory equipment used for oxygen delivery and nebulizer treatments.
Findings
The facility failed to date and label respiratory equipment and failed to change equipment used for oxygen delivery and nebulizer treatments for 7 of 8 residents reviewed. Interviews with staff revealed inconsistent adherence to weekly tubing changes and incomplete monitoring by responsible personnel.
Deficiencies (2)
Failure to date and label respiratory equipment used for oxygen delivery and nebulizer treatments.
Failure to change respiratory equipment tubing weekly as required for 7 of 8 residents reviewed.
Report Facts
Residents affected: 7
Date of survey completed: Jul 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN/UM | Registered Nurse/Unit Manager | Verified tubing was not dated and stated all tubing should be dated; responsible for respiratory therapy tubing changes |
| Respiratory Therapist | Respiratory Therapist | Stated tubing should be changed weekly and dated; denied supply shortages |
| Director of Nursing | Director of Nursing | Stated responsibility for monitoring tubing changes |
| Infection Prevention Nurse | Infection Prevention Nurse | Responsible for rounds and ensuring tubing was changed weekly; admitted not checking all tubing |
Inspection Report
Routine
Deficiencies: 8
Date: May 9, 2024
Visit Reason
Routine inspection of Complete Care at Orange Park nursing facility to assess compliance with healthcare regulations including resident rights, assessment accuracy, medication administration, pain management, physician visits, and kitchen sanitation.
Complaint Details
Complaint NJ00163003 related to Resident #512's medical record and physician progress notes.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs (assistance with mail), late submission and inaccurate coding of Minimum Data Set (MDS) assessments, medication administration errors, inadequate pain management documentation, untimely physician orders and visits, and kitchen sanitation violations such as jewelry worn by kitchen staff and improper storage and cleaning of refrigeration units.
Deficiencies (8)
Failure to provide assistance to open mail for a resident with bilateral hand contractures.
Failure to complete and submit electronically the Minimum Data Set (MDS) assessments within required timeframes for multiple residents.
Failure to accurately code the Minimum Data Set (MDS) for one resident.
Failure to follow acceptable standards for accurate medication administration and documentation for two residents and failure to follow physician's order for pain management for one resident.
Failure to ensure pain assessments were completed according to facility policy for two residents.
Failure to ensure residents' primary physicians signed and dated monthly physician orders and nurse practitioners accurately dated physician progress notes.
Failure to ensure responsible physicians conducted face-to-face visits and wrote progress notes at least every 60 days for multiple residents.
Failure to maintain proper kitchen sanitation practices including wearing prohibited jewelry and improper storage and cleaning of refrigeration units.
Report Facts
Residents affected: 39
Residents affected: 4
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 19
Residents affected: 21
Jewelry length: 1
Storage height: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Dietary Manager (CDM) | Observed wearing prohibited earrings in kitchen | |
| Chef | Observed wearing prohibited earrings in kitchen | |
| Licensed Practical Nurse #1 | LPN | Observed medication administration and interviewed about medication measuring |
| Licensed Practical Nurse #3 | LPN | Observed medication administration and interviewed about unavailable potassium packets |
| Licensed Practical Nurse #5 | LPN | Interviewed about pain level rating |
| Unit Manager #3 | Unit Manager | Interviewed about pain level rating |
| Regional Registered Nurse (RRN) | Regional RN | Discussed concerns about mail assistance, medication errors, and pain management |
| Licensed Nursing Home Administrator (LNHA) | Administrator | Discussed concerns and follow-up on multiple deficiencies |
| Director of Recreation and Volunteers (DRV) | Director | Interviewed about mail distribution process |
| MDS Coordinator/Registered Nurse (MDSC/RN) | RN | Interviewed about late MDS submissions and coding accuracy |
| Nurse Practitioner #1 | NP | Interviewed about physician progress notes and monthly orders |
| Physician MD #1 | Physician | Interviewed about physician visits and order signing |
| Regional Clinical Nurse (RCN) | Regional Nurse | Discussed concerns and facility policies |
| [NAME] | President of Clinical Nursing | Discussed physician order signing policy |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 9, 2024
Visit Reason
The inspection was conducted based on complaints regarding failure to accommodate resident needs and failure to provide pharmaceutical services according to professional standards.
Complaint Details
Complaint #NJ0016817 involved failure to provide pharmaceutical services including medication administration and availability for Resident #513. The complaint was substantiated with findings of minimal harm affecting few residents.
Findings
The facility failed to provide reasonable accommodation for a resident with bilateral hand contractures by not assisting with opening mail. Additionally, the facility failed to ensure accurate administration of medications and availability of ordered medications for one resident, with documentation and procedural failures noted.
Deficiencies (2)
Failed to provide assistance to open mail for a resident with bilateral hand contractures.
Failed to provide pharmaceutical services including accurate medication administration and availability of medications for one resident.
Report Facts
Residents reviewed for rights: 39
Residents reviewed for medication management: 11
BIMS score: 10
BIMS score: 14
Medication administration entries: 7
Medication administration entries: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Documented non-administration of medications and awaiting delivery; unable to explain failure to follow procedure. |
| LPN #6 | Licensed Practical Nurse | Documented non-administration of Midodrine due to low blood pressure; no longer employed at facility. |
| Regional Registered Nurse | Regional Registered Nurse (RRN) | Discussed mail distribution responsibilities and acknowledged medication administration failures. |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator (LNHA) | Participated in discussions regarding mail assistance and medication administration issues. |
| Assistant Licensed Nursing Home Administrator | Assistant LNHA | Participated in discussions regarding mail assistance and medication administration issues. |
| Director of Recreation and Volunteers | Director of Recreation and Volunteers (DRV) | Explained mail delivery and assistance procedures. |
| Consultant Pharmacist | Consultant Pharmacist (CP) | Provided expert opinion on medication administration procedures and follow-up. |
| Regional Clinical Nurse | Regional Clinical Nurse (RCN) | Acknowledged medication administration failures and procedural lapses. |
| Assistant Administrator | Assistant Administrator (AA) | Participated in medication administration issue discussions. |
Inspection Report
Complaint Investigation
Census: 181
Deficiencies: 1
Date: Jan 25, 2023
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint intake numbers related to allegations of abuse, neglect, and failure to report injuries of unknown origin.
Complaint Details
The complaint investigation involved multiple complaint intake numbers (NJ152448, NJ152897, NJ153708, NJ154069, NJ157542). The facility failed to report an injury of unknown origin for Resident #3, which was substantiated by the investigation.
Findings
The facility was found not in compliance with federal regulations for failing to report an injury of unknown origin involving Resident #3 to the state agency within the required timeframe. The investigation revealed the resident had fractures of unknown cause that were not reported promptly, violating reporting requirements.
Deficiencies (1)
Failure to report an injury of unknown origin to the required entities for Resident #3 within the required timeframe.
Report Facts
Census: 181
Sample Size: 16
Completion Date for Plan of Correction: Feb 1, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding failure to report injury and corrective actions |
| Administrator | Administrator | Interviewed regarding injury cause and reporting requirements |
Inspection Report
Complaint Investigation
Census: 150
Deficiencies: 0
Date: Jul 27, 2022
Visit Reason
The inspection was conducted as a complaint survey based on Complaint # NJ00156375.
Complaint Details
Complaint # NJ00156375 was investigated and the facility was found to be in compliance.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Report Facts
Sample Size: 3
Inspection Report
Routine
Census: 167
Deficiencies: 9
Date: Feb 9, 2022
Visit Reason
The inspection was a routine regulatory visit to assess compliance with healthcare facility regulations, including resident rights, environment, care, physician orders, medication storage, staffing, infection control, equipment maintenance, and safety.
Findings
The facility was found deficient in multiple areas including failure to maintain resident rights during medication administration, unsanitary environment conditions, inadequate nail care for residents, unsigned physician orders, improper insulin storage and labeling, insufficient nursing staff to meet resident needs, lapses in infection control practices, poorly maintained air conditioning units, and unsecured handrails throughout the facility.
Deficiencies (9)
Failure to maintain resident rights during medication administration by crushing medication and administering it without resident's knowledge.
Failure to maintain a clean and sanitary environment on 3 resident floors with multiple issues including dirty vents, broken fixtures, and missing privacy curtains.
Failure to provide nail care for residents unable to do it themselves, resulting in overgrown and infected nails.
Physicians failed to hand sign or electronically sign monthly physician orders for multiple residents over several months.
Failure to store insulin vials according to manufacturer specifications and failure to properly label insulin vials.
Insufficient nursing staff to meet residents' activities of daily living needs, with documented staffing shortages over multiple days.
Failure to follow infection control practices during medication administration, including inadequate hand hygiene and sanitizing of equipment.
Failure to maintain packaged terminal air conditioner (PTAC) units in safe and optimal condition with clogged and dirty filters in all units observed.
Failure to ensure wooden handrails were installed, secured, and splinter free in all required locations throughout the facility.
Report Facts
Residents affected by unsigned physician orders: 18
Medication carts inspected: 5
PTAC units observed: 102
Residents census: 167
Certified Nurse Aides (CNAs) required: 20
Certified Nurse Aides (CNAs) staffed: 9
Days with CNA staffing below minimum: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Observed crushing medication and administering it without resident's knowledge. | |
| Director of Nursing (DON) | Acknowledged concerns about medication administration and staffing shortages. | |
| Certified Nursing Assistant (CNA) #1 | Reported not cutting residents' nails and staffing shortages. | |
| Certified Nursing Assistant (CNA) #2 | Reported staffing shortages and inability to complete care tasks timely. | |
| Licensed Practical Nurse/Unit Manager (LPN/UM) | Responsible for cutting residents' nails and acknowledged deficiencies. | |
| Maintenance Director | Confirmed unsanitary conditions and PTAC maintenance issues. | |
| Administrator | Notified of deficiencies and involved in discussions. | |
| Staffing Coordinator | Acknowledged staffing shortages and recruitment efforts. | |
| Licensed Practical Nurse #1 and #2 | Observed lapses in infection control during medication administration. |
Inspection Report
Annual Inspection
Census: 166
Capacity: 215
Deficiencies: 20
Date: Feb 9, 2022
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including a COVID-19 Focused Infection Control Survey.
Findings
Deficiencies were cited related to residents' rights during medication administration, facility cleanliness and maintenance, ADL care, physician order signatures, medication labeling and storage, staffing shortages, infection control practices, life safety code violations including fire safety, electrical and HVAC maintenance, and elevator safety.
Deficiencies (20)
Failed to maintain residents' rights during medication administration by crushing medication and administering without resident knowledge.
Failed to maintain a clean and sanitary environment including dirty ceiling vents, broken PTAC units, stained ceiling tiles, and damaged walls.
Failed to provide nail care for dependent residents, resulting in overgrown nails and lack of grooming documentation.
Failed to ensure physicians signed and dated monthly physician orders for multiple residents.
Failed to store insulin vials according to manufacturer specifications and failed to properly label insulin.
Failed to maintain sufficient nursing staff to meet residents' ADL needs, resulting in inadequate care and unmet preferences.
Failed to follow effective infection control practices during medication administration, including improper sanitization and hand hygiene.
Failed to maintain PTAC units in safe and optimal condition with clogged and dirty filters.
Failed to ensure wooden handrails were installed, secured, and splinter free in all required locations.
Basement area had only one exit, failing to provide two approved exits as required.
Failed to provide automatic emergency illumination at the smoking courtyard egress gate.
Failed to provide emergency lighting above emergency generator transfer switches.
Failed to maintain self-closing devices on doors to hazardous areas, including combustible storage room door without self-closing device.
Failed to maintain elevator emergency communication telephones in working order; vendor contract expired and phones not answered.
Electrical panel face plate not properly secured, exposing live wires.
Failed to maintain sprinkler system including missing ceiling tiles and lack of quarterly inspection documentation.
Failed to ensure corridor doors resist passage of smoke and properly latch.
Smoke barrier door blocked from closing by linen cart.
Resident bathroom ventilation systems not functioning in two resident rooms.
Extension cords used as permanent wiring in resident room.
Report Facts
Deficiencies cited: 20
Census: 166
Total Capacity: 215
Staffing ratios: 20
Staffing ratios: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Named in infection control deficiency related to medication pass. |
| Licensed Practical Nurse #2 | LPN | Named in infection control deficiency related to medication pass. |
| Director of Nursing | DON | Involved in discussions and corrective actions for multiple deficiencies. |
| Maintenance Director | Maintenance Director | Named in multiple deficiencies related to facility maintenance and safety. |
| Certified Nursing Assistant #1 | CNA | Named in nail care deficiency. |
| Certified Nursing Assistant #2 | CNA | Named in nail care deficiency. |
| Licensed Practical Nurse/Unit Manager #1 | LPN/UM | Named in nail care deficiency. |
| Licensed Practical Nurse/Unit Manager #2 | LPN/UM | Named in nail care deficiency. |
| Licensed Practical Nurse/Unit Manager #3 | LPN/UM | Named in physician order deficiency. |
Inspection Report
Life Safety
Census: 166
Capacity: 215
Deficiencies: 12
Date: Feb 1, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health from 02/01/2022 to 02/03/2022 to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the NFPA 101 Life Safety Code.
Findings
The facility was found to have multiple life safety deficiencies including inadequate number of exits in the basement, lack of emergency illumination, failure to maintain self-closing doors on hazardous areas, fire alarm system deficiencies, sprinkler system maintenance issues, corridor doors not latching properly, smoke barrier doors blocked, HVAC ventilation failures in resident bathrooms, elevator emergency communication failures, exposed electrical panel wiring, and improper use of extension cords.
Deficiencies (12)
Basement area provided with only one exit, failing to provide two acceptable exits from each floor.
Failed to provide automatic emergency illumination at the smoking courtyard egress/discharge gate.
Failed to provide operational battery backup emergency light above the emergency generator's transfer switches.
Failed to provide and maintain self-closing devices and hardware on doors to hazardous areas.
Failed to provide and maintain supervised smoke/heat detection in operating condition; one smoke detector taped over.
Failed to maintain sprinkler system; missing ceiling tiles and incomplete quarterly inspections.
Corridor doors failed to resist passage of smoke; doors did not latch properly in 4 resident rooms and storage area.
Smoke barrier door blocked from fully closing by a linen cart.
Resident bathroom ventilation systems for 2 units not functioning properly.
Failed to maintain elevator emergency communication for 3 passenger elevators; vendor contract expired.
Electrical panel face plate not properly positioned exposing live wires.
Use of household grade extension cord in resident room as substitute for fixed wiring.
Report Facts
Certified beds: 215
Census: 166
Deficiency count: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and acknowledged multiple deficiencies including basement exits, emergency lighting, fire alarm, sprinkler system, corridor doors, smoke barrier doors, ventilation, elevator communication, and electrical panel issues. | |
| Administrator | Notified of all deficiencies at Life Safety Code exit conference on 02/03/2022. |
Inspection Report
Complaint Investigation
Census: 125
Deficiencies: 0
Date: Jun 29, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ142857, NJ139231, and NJ136076.
Complaint Details
Complaint numbers NJ142857, NJ139231, and NJ136076 were investigated and found to be unsubstantiated as the facility was in compliance.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Report Facts
Sample Size: 17
Inspection Report
Routine
Census: 137
Deficiencies: 0
Date: Mar 16, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 7
Inspection Report
Abbreviated Survey
Census: 140
Deficiencies: 1
Date: Jan 26, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found not to be in compliance with infection control regulations, specifically failing to ensure that staff adhered to proper hand hygiene practices. One Respiratory Therapist was observed not washing or sanitizing hands before donning gloves and after glove removal, posing a risk for infection transmission.
Deficiencies (1)
Failure to ensure staff performed handwashing as per facility policy to prevent spread of infection while rendering care to residents.
Report Facts
Sample size: 20
Audit frequency: 25
Audit duration: 2
Audit duration: 4
Audit duration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Respiratory Therapist | Observed failing to perform proper hand hygiene before and after glove use | |
| Director of Nursing/Infection Preventionist | Provided 1:1 education and handwashing competency training to Respiratory Therapist and re-educated all staff on hand hygiene policy |
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