Cycle 1
Health 2025-09-24 · Fire 2025-09-24
6 health deficiencies
Top issue: Environmental (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
East Orange, NJ
Complete Care At Orange Park
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
140 Park Ave, East Orange, NJ
(973) 677-1500
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
215
Certified beds
Average residents
199
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1981-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
85 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.42
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.08
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.25
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.17
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.09
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.84
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
11%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
18%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,104
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.26
Composite VBP score used to determine payment impact.
Payment multiplier
0.9942
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.77
Baseline 23.10% · Performance 19.90% · Measure score 4.77 · Achievement 3.30 · Improvement 4.77
Healthcare-associated infections
0.30
Baseline 8.14% · Performance 7.89% · Measure score 0.30 · Achievement 0 · Improvement 0.30
Total nurse turnover
10
Baseline 29.24% · Performance 17.52% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
1.43
Baseline 3.06 hours · Performance 3.49 hours · Measure score 1.43 · Achievement 1.43 · Improvement 1.07
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.09% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 83 · Observed rate 12.05% · Lower 95% interval 7.21% |
| Discharge to community | 44.03% |
50.57%
6.5 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 31.91% · Lower 95% interval 32.25% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 76 · Denominator 76 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 76 |
| Discharge self-care score | 76.74% |
53.69%
23 pts better
|
Numerator 33 · Denominator 43 |
| Discharge mobility score | 69.77% |
50.94%
18.8 pts better
|
Numerator 30 · Denominator 43 |
| Pressure ulcers or injuries, new or worsened | 3.95% |
2.29%
1.7 pts worse
|
Numerator 3 · Denominator 76 · Adjusted rate 4% |
| Healthcare-associated infections requiring hospitalization | 7.89% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 39 · Observed rate 12.82% · Lower 95% interval 4.73% |
| Staff COVID-19 vaccination coverage | 8.45% |
8.2%
0.2 pts better
|
Numerator 18 · Denominator 213 |
| Staff flu vaccination coverage | 97.21% |
42%
55.2 pts better
|
Numerator 209 · Denominator 215 |
| Discharge function score | 81.4% |
56.45%
25 pts better
|
Numerator 35 · Denominator 43 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 27 · Denominator 27 |
| Transfer of health information to patient | 95.24% |
96.28%
1 pts worse
|
Numerator 20 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 36 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
2.1
0.7 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.1
0.3 pts worse
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.2 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 76.6% |
93.0%
16.4 pts worse
|
93.4%
16.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 83.6% · Q2 78.4% · Q3 75.6% · Q4 69.1% · 4Q avg 76.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.2%
2.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.7% |
2.4%
1.7 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.5% · Q3 0.5% · Q4 1.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 14.7% |
11.4%
3.3 pts worse
|
11.4%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 18.8% · Q3 18.6% · Q4 6.7% · 4Q avg 14.7% |
| Percentage of long-stay residents who lose too much weight | 1.8% |
4.6%
2.8 pts better
|
5.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.2% · Q3 2.1% · Q4 1.6% · 4Q avg 1.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.3% |
19.0%
7.7 pts better
|
19.6%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 11.5% · Q3 10.5% · Q4 11.1% · 4Q avg 11.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.4% |
13.5%
3.9 pts worse
|
16.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 14.0% · Q3 18.4% · Q4 22.1% · 4Q avg 17.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 1.8% |
9.8%
8 pts better
|
16.3%
14.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.7% · Q3 3.1% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.4% |
9.7%
6.3 pts better
|
14.9%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 4.2% · Q3 2.3% · Q4 1.7% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.1% |
0.7%
0.6 pts better
|
1.0%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.0% |
15.9%
10.9 pts better
|
19.8%
14.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.7% · Q3 4.2% · Q4 6.2% · 4Q avg 5.0% |
| Percentage of long-stay residents with pressure ulcers | 7.6% |
6.0%
1.6 pts worse
|
5.1%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 7.8% · Q3 7.3% · Q4 7.3% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 60.2% |
78.7%
18.5 pts worse
|
81.7%
21.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 72.4% · Q2 63.8% · Q3 55.9% · Q4 43.8% · 4Q avg 60.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.9% |
8.2%
2.3 pts better
|
12.0%
6.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.9% · Observed 6.5% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
1.2%
1.2 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 3.6% · Q3 0.0% · Q4 2.2% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.2% |
80.1%
14.1 pts better
|
79.7%
14.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.4% |
25.4%
2 pts worse
|
23.9%
3.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.4% · Observed 28.3% · Expected 24.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-09 · Fire 2024-05-09
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2022-02-09 · Fire 2022-02-09
9 health deficiencies
Top issue: Environmental (2 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-24
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2025-09-25
F · Potential for more than minimal harm
2025-09-24
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-11-14
F · Potential for more than minimal harm
2025-09-24
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2025-11-14
F · Potential for more than minimal harm
2025-09-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-25
F · Potential for more than minimal harm
2025-09-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-09-25
F · Potential for more than minimal harm
2025-09-24
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-10-28
F · Potential for more than minimal harm
2025-09-24
K908 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2025-11-18
D · Potential for more than minimal harm
2025-09-24
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-09-25
F · Potential for more than minimal harm
2024-05-09
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-05-23
F · Potential for more than minimal harm
2024-05-09
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-05-23
F · Potential for more than minimal harm
2022-02-09
K252 · Egress Deficiencies
Fire Safety
Provide at least two remote exits on each floor or fire section of the building.
Corrected 2022-05-12
F · Potential for more than minimal harm
2022-02-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-05-11
F · Potential for more than minimal harm
2022-02-09
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-04-18
D · Potential for more than minimal harm
2022-02-09
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2022-04-13
D · Potential for more than minimal harm
2022-02-09
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-04-08
D · Potential for more than minimal harm
2022-02-09
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-04-13
D · Potential for more than minimal harm
2022-02-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-04-14
D · Potential for more than minimal harm
2022-02-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-05-11
D · Potential for more than minimal harm
2022-02-09
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-04-18
D · Potential for more than minimal harm
2022-02-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-04-14
D · Potential for more than minimal harm
2022-02-09
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-04-13
D · Potential for more than minimal harm
2022-02-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-04-13
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-09-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-11-14
E · Potential for more than minimal harm
2025-09-24
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2025-11-14
E · Potential for more than minimal harm
2025-09-24
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-11-14
D · Potential for more than minimal harm
2025-09-24
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-11-14
D · Potential for more than minimal harm
2025-09-24
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-11-14
E · Potential for more than minimal harm
2025-07-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-20
E · Potential for more than minimal harm
2024-05-09
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2024-05-28
E · Potential for more than minimal harm
2024-05-09
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2024-05-28
D · Potential for more than minimal harm
2024-05-09
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-05-09
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-05-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-05-09
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-05-28
D · Potential for more than minimal harm
2024-05-09
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-05-28
D · Potential for more than minimal harm
2024-05-09
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-05-28
D · Potential for more than minimal harm
2024-05-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-28
F · Potential for more than minimal harm
2022-02-09
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2022-04-08
E · Potential for more than minimal harm
2022-02-09
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2022-04-18
E · Potential for more than minimal harm
2022-02-09
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2022-04-08
E · Potential for more than minimal harm
2022-02-09
F924 · Environmental Deficiencies
Health
Put firmly secured handrails on each side of hallways.
Corrected 2022-04-18
D · Potential for more than minimal harm
2022-02-09
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-04-13
D · Potential for more than minimal harm
2022-02-09
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-04-08
D · Potential for more than minimal harm
2022-02-09
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-02-22
D · Potential for more than minimal harm
2022-02-09
F836 · Administration Deficiencies
Health
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.
Corrected 2022-05-12
D · Potential for more than minimal harm
2022-02-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-09
Penalties and ownership
What sits behind the stars
Ownership
East Orange Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Clarke, Robert
Operational/Managerial Control · Individual
Eef Capital LLC
5% Or Greater Indirect Ownership Interest · Organization
Gottlieb, Yehuda
Operational/Managerial Control · Individual
Grewal, Baljinder
Operational/Managerial Control · Individual
Levovitz, Yitz
Operational/Managerial Control · Individual
Mercado, Wanda
Operational/Managerial Control · Individual
Pc East Orange Holdco
5% Or Greater Indirect Ownership Interest · Organization
Peace Capital Holdings LLC (De)
5% Or Greater Indirect Ownership Interest · Organization
Schlaff, Benny
5% Or Greater Indirect Ownership Interest · Individual
Schlaff, Nachum
5% Or Greater Indirect Ownership Interest · Individual
Sms 2021 Trust
5% Or Greater Indirect Ownership Interest · Organization
Stein, Shalom
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Grove Park Healthcare And Rehabilitation Center
East Orange, NJ
3-star overall rating with 2-star inspections with 10 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Park Crescent Healthcare & Rehabilitation Center
East Orange, NJ
4-star overall rating with 3-star inspections with $15,240 in total fines with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Job Haines Home For Aged People
Bloomfield, NJ
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
Jump out