A list of the most recent deficiencies for Complete Care at Orange Park. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-25 | 2023-02-01 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2022-02-09 | 2022-05-12 | N |
| Provide at least two remote exits on each floor or fire section of the building. | Fire Safety | 2022-02-09 | 2022-05-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-09 | 2022-05-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-09 | 2022-05-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-09 | 2022-05-09 | N |
| 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. | Health | 2022-02-09 | 2022-04-18 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2022-02-09 | 2022-04-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-02-09 | 2022-04-18 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-02-09 | 2022-04-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-02-09 | 2022-04-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-02-09 | 2022-04-14 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-02-09 | 2022-04-13 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-02-09 | 2022-04-13 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-02-09 | 2022-04-13 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-02-09 | 2022-04-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-09 | 2022-04-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-09 | 2022-04-08 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2022-02-09 | 2022-04-08 | N |
| Keep all essential equipment working safely. | Health | 2022-02-09 | 2022-04-08 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-02-09 | 2022-04-08 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-02-09 | 2022-02-22 | N |
| Provide at least two remote exits on each floor or fire section of the building. | Fire Safety | 2020-02-24 | 2020-08-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-02-24 | 2020-05-15 | N |
| 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. | Health | 2020-02-24 | 2020-03-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-24 | 2020-03-16 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-02-06 | 2019-04-01 | N |
| 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. | Health | 2019-02-06 | 2019-04-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-02-06 | 2019-04-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-02-06 | 2019-04-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-02-06 | 2019-04-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-06 | 2019-04-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-02-06 | 2019-04-01 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-02-06 | 2019-04-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-06 | 2019-04-01 | N |
| Keep all essential equipment working safely. | Health | 2019-02-06 | 2019-04-01 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-02-06 | 2019-04-01 | N |
| Provide at least two remote exits on each floor or fire section of the building. | Fire Safety | 2019-02-06 | 2019-04-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-02-06 | 2019-04-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-06 | 2019-04-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-06 | 2019-04-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-02-06 | 2019-04-01 | N |
