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Data from CMS, Census Bureau & CareScout. Not affiliated with the U.S. government.

© 2026 NursingHomes.us. All data from CMS.gov.
HomeNew JerseyComplete Care at Milford Manor LLC

Complete Care at Milford Manor LLC

69 Maple Road, West Milford, NJ 074809736975640
2/5Below Average
Accepts Medicare Accepts Medicaid Sprinkler System
Health
2/5
Staffing
2/5
Quality
4/5
Beds
120
certified
1 fine(s) totaling $3,595

Key Findings

• CMS rates this facility 2/5 stars (below average)

• Has 120 certified beds with an average of 104.9 residents per day (87% occupancy)

• Last health inspection found 14 deficiencies (inspected Mar 7, 2025)

• Has been fined a total of $3,595 across 1 fine(s)

• Total nursing staff: 3.45 hours per resident per day

• Staff turnover rate: 51.7% (high)

• Part of the Complete Care chain (85 facilities)

Complete Care at Milford Manor LLC is a 2-star Medicare and Medicaid certified nursing home in West Milford, New Jersey with 120 certified beds. It has been operating since 1989. The facility scored below average compared to New Jersey facilities.

Beds
120
Avg Residents/Day
104.9
Ownership
For profit - Corporation
Provider Type
Medicare and Medicaid
In Hospital
No
First Approved
Jun 1, 1989
Sprinklers
Yes
Council
Resident
County
Passaic
Last Inspection
Mar 7, 2025
Deficiencies (Cycle 1)
14
Weighted Score
81.0
Infection Citations
0

Deficiency Citations (26)

F0684Potential for Harm

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey: Jun 25, 2025Corrected: NoCycle: 1
F0580Potential for Harm

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey: Mar 7, 2025Corrected: NoCycle: 1
F0583Potential for Harm

Keep residents' personal and medical records private and confidential.

Survey: Mar 7, 2025Corrected: NoCycle: 1
F0686Potential for Harm

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey: Mar 7, 2025Corrected: NoCycle: 1
F0692Potential for Harm

Provide enough food/fluids to maintain a resident's health.

Survey: Mar 7, 2025Corrected: NoCycle: 1
F0697Actual Harm

Provide safe, appropriate pain management for a resident who requires such services.

Survey: Mar 7, 2025Corrected: NoCycle: 1
F0757Potential for Harm

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Survey: Mar 7, 2025Corrected: NoCycle: 1
F0803Potential for Harm

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Survey: Mar 7, 2025Corrected: NoCycle: 1
F0842Potential for Harm

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey: Mar 7, 2025Corrected: NoCycle: 1
F0880Potential for Harm

Provide and implement an infection prevention and control program.

Survey: Mar 7, 2025Corrected: NoCycle: 1
F0883Potential for Harm

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Survey: Mar 7, 2025Corrected: NoCycle: 1
F0945Potential for Harm

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Survey: Mar 7, 2025Corrected: NoCycle: 1
F0946Potential for Harm

Provide training in compliance and ethics.

Survey: Mar 7, 2025Corrected: NoCycle: 1
F0949Potential for Harm

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Survey: Mar 7, 2025Corrected: NoCycle: 1
F0578Potential for Harm

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey: Feb 18, 2023Corrected: NoCycle: 2
F0656Potential for Harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey: Feb 18, 2023Corrected: NoCycle: 2
F0660Potential for Harm

Plan the resident's discharge to meet the resident's goals and needs.

Survey: Feb 18, 2023Corrected: NoCycle: 2
F0689Potential for Harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey: Feb 18, 2023Corrected: NoCycle: 2
F0697Potential for Harm

Provide safe, appropriate pain management for a resident who requires such services.

Survey: Feb 18, 2023Corrected: NoCycle: 2
F0755Potential for Harm

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey: Feb 18, 2023Corrected: NoCycle: 2
F0759Potential for Harm

Ensure medication error rates are not 5 percent or greater.

Survey: Feb 18, 2023Corrected: NoCycle: 2
F0812Potential for Harm

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey: Feb 18, 2023Corrected: NoCycle: 2
F0880Potential for Harm

Provide and implement an infection prevention and control program.

Survey: Jan 5, 2024Corrected: NoCycle: 3
F0761Potential for Harm

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.

Survey: Mar 8, 2021Corrected: NoCycle: 3
F0812Potential for Harm

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey: Mar 8, 2021Corrected: NoCycle: 3
F0880Potential for Harm

Provide and implement an infection prevention and control program.

Survey: Mar 8, 2021Corrected: NoCycle: 3
Total Fines
$3,595
Number of Fines
1
Payment Denials
0
Total Penalties
1

Penalty History

FineMar 7, 2025
$3,595

Staffing hours per resident per day. The black line shows the national average.

Nurse Aide2.15 hrs
National avg: 2.35 hrs
LPN0.77 hrs
National avg: 0.86 hrs
RN0.53 hrs
National avg: 0.68 hrs
Total Nursing3.45 hrs
National avg: 3.89 hrs
Weekend Total2.84 hrs
National avg: 0.00 hrs
Physical Therapist0.05 hrs
National avg: 0.07 hrs
Total Turnover
51.7%
RN Turnover
66.7%
Administrators Left
0

Quality measures as percentages of residents. Lower is better for all measures.

Ownership Type
For profit - Corporation
Recent Change
No

Owners & Managers (8)

NameRoleTypeOwnership %Since
MILFORD MANOR HOLDCO LLC5% OR GREATER DIRECT OWNERSHIP INTERESTOrganization100%Dec 27, 2021
PC GC HOLDCO LLC5% OR GREATER INDIRECT OWNERSHIP INTERESTOrganizationN/ADec 27, 2021
PEACE CAPITAL HOLDINGS LLC (DE)5% OR GREATER INDIRECT OWNERSHIP INTERESTOrganizationN/ADec 27, 2021
SMS 2021 TRUST5% OR GREATER INDIRECT OWNERSHIP INTERESTOrganizationN/ADec 27, 2021
AYDIN, EMMANUELOPERATIONAL/MANAGERIAL CONTROLIndividualN/ADec 27, 2021
REYES, GRACEOPERATIONAL/MANAGERIAL CONTROLIndividualN/AMar 13, 2023
ZACKAI, RAANANOPERATIONAL/MANAGERIAL CONTROLIndividualN/ADec 27, 2021
STEIN, SHALOMCORPORATE OFFICERIndividualN/ADec 27, 2021

Frequently Asked Questions

What is the CMS rating for Complete Care at Milford Manor LLC?▾
Complete Care at Milford Manor LLC has an overall CMS rating of 2 out of 5 stars, with a health inspection rating of 2/5, staffing rating of 2/5, and quality measures rating of 4/5. This facility is rated below average.
Has Complete Care at Milford Manor LLC had any health inspection violations?▾
Complete Care at Milford Manor LLC had 14 deficiency citations in its most recent health inspection (Mar 7, 2025). The facility has been fined a total of $3,595 across 1 fine(s).
What are the staffing levels at Complete Care at Milford Manor LLC?▾
Complete Care at Milford Manor LLC provides 3.45 total nursing staff hours per resident per day, including 0.53 RN hours, 0.77 LPN hours, and 2.15 nurse aide hours. The total staff turnover rate is 51.7%.
How many beds does Complete Care at Milford Manor LLC have?▾
Complete Care at Milford Manor LLC has 120 certified beds with an average of 104.9 residents per day, resulting in approximately 87% occupancy. The facility is For profit - Corporation owned and is part of the Complete Care chain.

Part of Complete Care

This chain operates 85 facilities. View all →