Complete Care at Milford Manor LLC
69 Maple Road, West Milford, NJ 07480
Complete Care at Milford Manor LLC is a nursing home in West Milford, New Jersey. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating2 of 5
- Last standard health inspectionMarch 7, 2025 (1 year ago)
- Health citations since March 8, 202126 (New Jersey average 24)
- Fines in the past three years1, $3,595 in total
- CMS flagsNone listed by CMS
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One email per CMS update, only when something changed: a new citation, a fine, a star rating change, a new owner. Early access follows one home per address.
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Staffing
Total nurse staffing reported to CMS went from 3.5 to 3.1 hours per resident per day.
Health inspection on June 25, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on July 25, 2025.
CMS update of June 25, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
Health inspection on March 7, 2025
13 citationsCMS lists this as a standard inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
27 of 348 New Jersey homes (8%) got a citation at the actual harm level in 2025.
CMS fine of $3,595 on March 7, 2025.
Show the 13 citations
Citation F0697. Severity G: actual harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on March 10, 2025.
CMS has cited this home for F0697 2 times since 2023.
Citation F0803. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on March 10, 2025.
Citation F0883. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on March 10, 2025.
Citation F0945. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
CMS lists it as corrected on March 10, 2025.
Citation F0946. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide training in compliance and ethics.
CMS lists it as corrected on March 10, 2025.
Citation F0949. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
CMS lists it as corrected on March 10, 2025.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on March 10, 2025.
Citation F0583. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep residents' personal and medical records private and confidential.
CMS lists it as corrected on March 10, 2025.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on March 10, 2025.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on March 10, 2025.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on March 10, 2025.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on March 10, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on March 10, 2025.
CMS has cited this home for F0880 3 times since 2021.
Fire safety inspection on March 7, 2025
3 citationsCMS lists this as a standard inspection.
Show the 3 citations
Citation K0355. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on March 8, 2025.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on March 8, 2025.
CMS has cited this home for K0712 2 times since 2023.
Citation K0914. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
CMS lists it as corrected on March 8, 2025.
CMS update of October 30, 2024
Staffing
Total nurse staffing reported to CMS went from 3.6 to 3.1 hours per resident per day.
CMS update of April 25, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of March 28, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
CMS update of January 31, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
Staffing
Total nurse staffing reported to CMS went from 3.4 to 3.1 hours per resident per day.
Health inspection on January 5, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on January 26, 2024.
Health inspection on February 18, 2023
8 citationsCMS lists this as a standard inspection.
Show the 8 citations
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on March 31, 2023.
CMS has cited this home for F0812 2 times since 2021.
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on March 31, 2023.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on March 31, 2023.
Citation F0660. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Plan the resident's discharge to meet the resident's goals and needs.
CMS lists it as corrected on March 31, 2023.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on March 31, 2023.
Citation F0697. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on March 31, 2023.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on March 31, 2023.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on March 31, 2023.
Fire safety inspection on February 18, 2023
8 citationsCMS lists this as a standard inspection.
Show the 8 citations
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on March 31, 2023.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on March 31, 2023.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on April 19, 2023.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on March 31, 2023.
Citation K0351. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install an approved automatic sprinkler system.
CMS lists it as corrected on April 19, 2023.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on March 31, 2023.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on March 31, 2023.
Citation K0781. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have restrictions on the use of portable space heaters.
CMS lists it as corrected on March 31, 2023.
Health inspection on March 8, 2021
3 citationsCMS lists this as a standard inspection.
Show the 3 citations
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on March 19, 2021.
Citation F0812. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on March 19, 2021.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on April 6, 2021.
CMS star ratings
- 2 of 5CMS overall star rating
- 2 of 5CMS health inspection star rating
- 2 of 5CMS staffing star rating
- 4 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (973) 697-5640
- Last standard health inspection
- March 7, 2025 (1 year ago)
- Certified beds
- 120
- Residents per day, on average
- 114.1
- Ownership type
- For profit - Corporation
- Legal business name
- Complete Care at Milford Manor LLC
- Chain
- Complete Care
- Takes part in
- Medicare and Medicaid
More health citations than the New Jersey average (26 vs 24).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- MILFORD MANOR HOLDCO LLC5% or greater direct ownership interest · 100% · since 12/27/2021
- PC GC HOLDCO LLC5% or greater indirect ownership interest · no percentage provided · since 12/27/2021
- SMS 2021 TRUST5% or greater indirect ownership interest · no percentage provided · since 12/27/2021
- STEIN, SHALOMIndirect ownership interest · not applicable · since 12/27/2021
- AYDIN, EMMANUELOperational/managerial control · not applicable · since 12/27/2021
Show 2 more
- REYES, GRACEOperational/managerial control · not applicable · since 03/13/2023
- ZACKAI, RAANANOperational/managerial control · not applicable · since 12/27/2021
Questions
When was Complete Care at Milford Manor LLC last inspected?
CMS lists March 7, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Complete Care at Milford Manor LLC have?
CMS lists 26 health citations since March 8, 2021. CMS also calls these deficiencies.
Has Complete Care at Milford Manor LLC been fined?
CMS lists 1 fine in the past three years, $3,595 in total.
What is the CMS star rating of Complete Care at Milford Manor LLC?
Its CMS overall star rating is 2 of 5.
Is Complete Care at Milford Manor LLC a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.