Complete Care At Orange Park

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

44.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 47 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 75.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 37 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.14 therapist hours per resident per day in 2026Q1 — more than 11% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 23% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 215 beds and averages 206.4 residents a day — about 96% occupied, or roughly 9 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.14 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.00 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.89 hrs/resident/day on weekends vs 3.24 on weekdays — 11% thinner on weekends. RN hours go from 0.40 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 17% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.

• Potential for harm · Fcited before2025-09-24 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 09/18/2025 from 9:37 AM until 10:06 AM, the surveyor observed the following in the kitchen in the presence of the Dietary Director (DD): 1.The Food Service Worker (FSW#1) had facial hair and was not wearing beard guard. The DD#1 stated the FSW#1 should have a beard guard. 2. In the walk-in refrigerator, a prepared salad had a label which reflected prep 9/15 expire 9/17. The DD stated it was out of date and threw the salad out.3. In the walk-in refrigerator, a plastic bag of fresh basil dated 9/10 with soft brown areas on several leaves. The DD stated the basil looks a little soft gonna toss it. 4. The Food Service Worker (FSW#2) had facial hair and was not wearing beard guard. The DD stated the FSW#2 should have a beard guard. A review of facility provided policy titled, [NAME] Guard Policy, with a revision…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-09-24 · tag F0712 — pattern
  Ensure that the resident and his/her doctor meet face-to-face at all required visits.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Complaint #425693Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that residents must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter. The deficient practice was identified for 1 of 2 (Resident # 167) residents reviewed for Physician Visits. The deficient practice was evidenced by the following: A review of Resident # 167's Electronic Medical Record (EMR) revealed he/she was admitted in March of 2025.A review of Resident # 167's EMR revealed he/she was diagnosed with but not limited to unspecified sequelae of cerebral infarction (long term conditions of a stroke) and type 2 diabetes mellitus without complications (inability to control blood-sugar).A review of the Progress Notes for Resident # 167 revealed a late entry by a Physician that was created on 04/14/2025 and dated for 03/30/2025.A review of Resident # 167's EMR did not reveal any other documented visits from the Physician.A review of the Progress Notes…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-09-24 · tag F0919 — failed to provide a working call system — pattern
  Make sure that a working call system is available in each resident's bathroom and bathing area.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews from 09/18/2025 to 09/22/2025 in the presence of the Regional Maintenance Director (RMD) and the Maintenance Director (MD), it was determined that the facility failed to ensure that the resident call bell system was properly functioning in all areas. This deficient practice had the potential to affect 3 residents and was evidenced by the following:Observations on 09/19/2025 from 10:14 AM to 11:01 AM revealed the following:The call bell cord was missing from resident room [ROOM NUMBER]. The resident was in bed at the time. The surveyor asked the resident how long the call bell cord has been missing and the resident stated, For a couple of days. Additionally, there was no indication that the call bell cord was missing at the call bell system annunciator panel.Visual notification of the activation of the call bell system was not provided at the call bell annunciator panel when testing the call bell for resident room [ROOM NUMBER]. The indicating bulb was not functioning.The call…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-09-24 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain a clean and sanitary environment for 2 of 3 units, the first floor second floor.This deficient practice was evidenced by the following: During initial tour on 09/18/2025 at 10:02 AM survey #1 observed the following: 1. A hole in the wall behind the door of room [ROOM NUMBER]. 2. In room [ROOM NUMBER] the molding at the bottom of the wall was peeling off and there were two tiles with peeling at the edges. On 09/18/2025 at 10:24 AM during the initial tour of the facility in room [ROOM NUMBER], the Surveyor observed a scissors with soiled adhesive surgical tape attached to it on the windowsill. On the same date at 10:32 AM while in the shower room outside of room [ROOM NUMBER], the Surveyor observed geriatric recliners, a wheelchair, and mechanical lift stored in the shower room. Within the bathroom area of the shower room, the Surveyor observed a broken toilet paper holder and toilet…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-24 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
  Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to obtain a Physician's Order (PO) for an orthotic device for 1 of 2 residents (Resident#80) reviewed for positioning and mobility. On 09/18/2025 at 11:36 AM, the surveyor observed resident #80 in a wheelchair. An orthotic device was observed on the left leg of Resident #80. According to the admission Record, Resident #80 was admitted to the facility with a diagnosis including but not limited to left foot drop. Review of the Annual Minimum Data Set (MDS), an assessment tool utilized to facilitate the management of care, dated 07/01/2025 reflected that the resident was cognitively intact and had impaired use of the lower extremity on one side of the body. Review of the Order Summary Report with active orders as of 09/21/2025 did not reveal an order for Resident #80's orthotic device for the left leg. Review of Resident #80's current Care Plan did not reflect the use of the orthotic device. During an interview with the surveyor on 09/22/2025 at 11:13…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-07-15 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and review of pertinent facility documents on 7/14/25 and 7/15/25, it was determined the facility failed to a.) date and label respiratory equipment used for oxygen delivery and nebulizer treatments and b.) change equipment used for oxygen delivery and nebulizer treatments for 7 of 8 residents (Residents #1, #2, #3, #4, #5, #10 and #11) reviewed for respiratory care. This deficient practice was evidenced by the following:On 7/14/25 at 10:13 AM, surveyor conducted rounds on the oxygen, the Tracheotomy/Ventilator (trach/vent), and treatment tubing, with the Registered Nurse/Unit Manager (RN/UM) of the trach/vent unit and observed the following: 1. Resident #10 was observed in bed awake. Resident #10 was non-verbal, and unable to respond to questions. The surveyor observed a nebulizer setup that was attached to a nebulizer machine. The tubing for the nebulizer setup was not dated. The in-line suctioning that was connected to the tracheostomy was observed to not have a date. The…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-05-09 · tag F0711 — pattern
  Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined that the facility failed to ensure that a). the residents' primary physician signed and dated monthly physician orders for residents under their care and b). facility failed to ensure that the resident's nurse practitioner (NP) accurately dated physician progress notes (PPN) during their visit to ensure that the resident's current medical regimen was up to date. The deficient practice was identified for 19 of 35 residents, Residents #53, #77, #172, #183, #86, #134, #105, #30, #171, #460, #92, #56, #57, #64, #37, #22, #18, #109, and #144 reviewed for physician orders and NP visits. The findings are as follows. 1. The surveyor interviewed Resident #53 on 4/30/24 at 10:00 AM. The resident was awake and alert in bed. A review of the medical record revealed the following information. The resident was admitted with diagnoses including but not limited to spina bifida and peripheral vascular disease. The 4/26/24 Quarterly Minimum Data Set (QMDS), assessment tool…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-05-09 · tag F0712 — pattern
  Ensure that the resident and his/her doctor meet face-to-face at all required visits.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that 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 deficient practice was identified for 21 of 36 residents (77, 105, 30, 172, 183, 86, 134, 171, 72, 35, 92, 56, 64, 37, 22, 18, 109, 187, 144, 191, 512) reviewed for physician visits and was evidenced by the following: 1. On 4/29/24 at 11:16 AM, the surveyor observed Resident #77 in bed. When interviewed, Resident #77 was noted alert and responsive. The surveyor reviewed the admission Record (one page summary of important information about a resident) for Resident #77. The resident was admitted to the facility with diagnoses that included but were not limited to right knee contracture and pyogenic arthritis. A review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/15/24, reflected that Resident #77 had a…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-05-09 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
  Reasonably accommodate the needs and preferences of each resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, it was determined that the facility failed to provide reasonable accommodation of resident needs specifically by failing to ensure that assistance was provided to open a mail for a resident with bilateral hand contractures for 1 of 39 residents, Resident #23, reviewed for resident rights. The deficient practice was evidenced by the following: 1. On 5/1/24 at 10:48 AM, the surveyor observed Resident #23 in bed, awake. The surveyor also observed that the resident was wearing hand splint (an orthotic device that is used to support and immobilize the hand, fingers and wrist) to both hands. The surveyor observed several unopened mails placed on top of the resident's nightstand and another one unopened mail placed on top of the bedside table. The surveyor interviewed the resident who stated that he/she would love for someone to open his/her mails for them in his/her presence. Resident #23 further stated that there were no staff who offered to open the mails for him/her. A review of the facility admission Record for Resident #23 revealed…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-05-09 · tag F0640 — isolated
  Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on the interview and record review, it was determined that the facility failed to complete and submit electronically the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, within 14 days of completing the resident's assessment and in accordance with the Center's for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. This deficient practice was identified for 4 of 35 residents (Residents #18, 22, 57, and 64). This deficient practice was evidenced by the following: 1. Resident #18 was observed to have an Annual MDS (AnMDS) with an Assessment Reference Date (ARD) on 6/30/23 was due to be transmitted to CMS no later than 7/14/23. However, the AnMDS was not submitted to CMS until 8/4/23. A review of Quarterly MDS (QMDS) with an ARD on 8/20/23 was due to be transmitted to CMS no later than 9/3/23. However, the QMDS was not submitted until 9/12/23. A review of QMDS with an ARD on 11/16/23 was due to be transmitted to CMS no later than 11/29/23. However, the QMDS was not submitted until 12/6/23. 2.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to COMPLETE CARE — 85 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 27 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.

6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

About 89% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $3.7M paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NJ