Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
COMPLETE CARE AT ORANGE PARK
EAST ORANGE, NJ · 215 certified beds · Last Life Safety survey September 24, 2025
CMS Certification Number 315178 · first certified July 1981
Ownership
Operated by COMPLETE CARE · For profit - Limited Liability company
- Ownership changed October 19, 2021 (change of ownership)from WINDSOR GARDENS CARE CENTER, INC.
Position within NJ
22 citations — more than 80% of the 348 certified nursing homes in NJ. Compared within NJ rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 8 citations; the earlier surveys in the window averaged 7. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens January 2027 — about 3 months from now. This facility’s last Life Safety survey was September 2025. Facilities in NJ are typically surveyed 16–20 months after the last one (median 17), measured over 431 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
7 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 22 Life Safety citations above. The Physical Environment Index
- F-0584 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.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
- F-0880 Provide and implement an infection prevention and control program.
- F-0908 Keep all essential equipment working safely.
- F-0924 Put firmly secured handrails on each side of hallways.
How that compares
Compared with the median facility in NJ, and nationally. Surveyors differ markedly between states, so the NJ figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 22 |
| Median facility in NJ | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| February 9, 2022 | 12 |
| May 9, 2024 | 2 |
| September 24, 2025 | 8 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0531 | Have elevators that firefighters can control in the event of a fire. | 2 | 2025-09-24 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-09-24 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2025-09-24 |
| K-0311 | Have an enclosure around a vertical opening shaft. | 1 | 2024-05-09 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 1 | 2025-09-24 |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | 1 | 2022-02-09 |
| K-0342 | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | 1 | 2025-09-24 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 1 | 2022-02-09 |
What the citations cover
- Smoke Deficiencies 10
- Egress Deficiencies 5
- Services Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 3
| Category | Citations |
|---|---|
| Smoke Deficiencies | 10 |
| Egress Deficiencies | 5 |
| Services Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 24, 2025 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (September 25, 2025) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (November 14, 2025) |
| K-0342 | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Deficient, Provider has date of correction (November 14, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 25, 2025) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (September 25, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (September 25, 2025) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (October 28, 2025) |
| K-0908 | Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Deficient, Provider has date of correction (November 18, 2025) |
May 9, 2024 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (May 23, 2024) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (May 23, 2024) |
February 9, 2022 — 12 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0252 | Provide at least two remote exits on each floor or fire section of the building. | Waiver has been granted (May 12, 2022) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (April 13, 2022) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (April 8, 2022) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (April 13, 2022) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (April 14, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 11, 2022) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (May 11, 2022) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (April 18, 2022) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (April 14, 2022) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (April 18, 2022) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (April 13, 2022) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (April 13, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.