Complete Care at Orange Park

In the surveyor’s words

From the most serious findings on record at Complete Care at Orange Park, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Sep 24, 2025

  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 The DD stated it was out of date and threw the salad out.3. […]

• No harm, potential for more than minimal, widespreadF711Feb 9, 2022

  Based on interview and record review, it was determined that the facility failed to ensure that the residents' primary physician signed and dated monthly physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice was observed for 18 of 33 residents (Resident #48, #59, #76, #34, #100, #51, #71, #144, #41, #32, #86, #99, #149, #128, #137, #78, #55, and #60) reviewed and occurred over several months. This deficient practice was evidenced by the following: The surveyors reviewed the hybrid medical records (paper and electronic) for the residents listed above that revealed the residents primary physician had not hand signed the Order Summary Reports (monthly physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. […]

• No harm, potential for more than minimal, patternF712Sep 24, 2025

  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… […]

• No harm, potential for more than minimal, patternF919Sep 24, 2025

  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. […]

• No harm, potential for more than minimal, patternF880Jul 15, 2025

  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. […]