nursing home in West Milford, NJ
Complete Care at Milford Manor LLC
69 Maple Road, West Milford, NJ 07480 · (973) 697-5640
★★★★★1
Much below average
CMS overall star rating
CMS overall star rating
- Health inspections★★★★★2
- Staffing★★★★★1
- Quality measures★★★★★4
Source: Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. We refresh our information from this source. About our data
Complete Care at Milford Manor LLC at a glance
Complete Care at Milford Manor LLC is a 120-bed for-profit nursing home in West Milford, New Jersey (Passaic County).
CMS gives it 1 out of 5 stars on its overall star rating, worse than the New Jersey average of 3.3.
Residents receive about 3 hours of nursing care per day (0.4 of them from registered nurses), worse than the state average of 3.8 hours.
Its most recent standard health inspection (March 7, 2025) found 13 health citations. The New Jersey average is 8.5.
Federal regulators fined it 1 time in the past three years, totaling $3,595.
Nursing staff turnover is 53.6% per year (state average 39.7%).
Facility details
- Type
- Nursing home
- Ownership
- For Profit - Corporation
- Beds
- 120
- Certified for
- Medicare and Medicaid
- Chain / affiliated entity
- Complete Care
- Medicare-certified since
- June 1, 1989
- Resident/family council
- Resident
- County
- Passaic County
- CMS Certification Number
- 315276
Ratings
| Measure | This facility | New Jersey avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Overall star rating ⓘ (higher is better) | 1 / 5 | 3.3 / 5 | 3 / 5 | Worse |
| Health inspection rating ⓘ (higher is better) | 2 / 5 | 2.8 / 5 | 2.8 / 5 | Worse |
| Staffing rating ⓘ (higher is better) | 1 / 5 | 3.1 / 5 | 2.9 / 5 | Worse |
| Quality measures rating ⓘ (higher is better) | 4 / 5 | 4.4 / 5 | 3.6 / 5 | Average |
| Long-stay quality rating (higher is better) | 4 / 5 | 4.5 / 5 | 3.8 / 5 | Average |
| Short-stay (rehab) quality rating (higher is better) | 3 / 5 | 4.1 / 5 | 3.3 / 5 | Average |
Staffing
| Measure | This facility | New Jersey avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Total nurse staff hours per resident per day ⓘ (higher is better) | 2.97 hrs | 3.85 hrs | 3.86 hrs | Worse |
| Registered nurse hours per resident per day (higher is better) | 0.42 hrs | 0.68 hrs | 0.69 hrs | Worse |
| Nurse aide hours per resident per day (higher is better) | 1.82 hrs | 2.23 hrs | 2.32 hrs | Worse |
| Weekend nurse staff hours per resident per day (higher is better) | 2.44 hrs | 3.50 hrs | 3.42 hrs | Worse |
| Nursing staff turnover (yearly) (lower is better) | 53.6% | 39.7% | 45.8% | Worse |
| Registered nurse turnover (yearly) (lower is better) | 50% | 37.7% | 42.9% | Worse |
| Administrators who left in the past year (lower is better) | 1 | 1 | 1 | Worse |
Inspections
| Measure | This facility | New Jersey avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Health citations in the most recent inspection (lower is better) | 13 | 9 | 9 | Worse |
| Citations from complaint investigations (latest cycle) (lower is better) | 0 | 1 | 3 | Better |
| Weighted health inspection score ⓘ (lower is better) | 79 | 72.3 | 80.6 | Average |
Penalties
| Measure | This facility | New Jersey avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Fines in the past 3 years (lower is better) | 1 | 1 | 1 | Worse |
| Total fines in the past 3 years (lower is better) | $3,595 | $34,926 | $30,972 | Better |
| All federal penalties in the past 3 years (lower is better) | 1 | 1 | 1 | Average |
Size
| Measure | This facility | New Jersey avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Certified beds | 120 | 147 | 107 | |
| Average residents per day | 112 | 122 | 86 | |
| Occupancy | 93.1% | 84% | 80.9% |
Long-stay residents
| Measure | This facility | New Jersey avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Long-stay residents with a fall causing major injury (lower is better) | 2.9% | 2.3% | 3.2% | Better |
| Long-stay residents with pressure ulcers (lower is better) | 2.6% | 5.4% | 4.6% | Better |
| Long-stay residents given antipsychotic medication (lower is better) | 14.9% | 12.7% | 15.4% | Average |
| Long-stay residents with a urinary tract infection (lower is better) | 0.6% | 0.8% | 1.6% | Better |
| Long-stay residents with a catheter left in the bladder (lower is better) | 0% | 0.6% | 0.8% | Better |
| Long-stay residents needing more help with daily activities (lower is better) | 14% | 8.7% | 13.9% | Average |
| Long-stay residents whose walking worsened (lower is better) | 7% | 8.2% | 14.1% | Better |
| Long-stay residents who lose too much weight (lower is better) | 3.6% | 4.6% | 5.2% | Better |
| Long-stay residents with depressive symptoms (lower is better) | 22.3% | 12.1% | 12.8% | Worse |
| Long-stay residents who were physically restrained (lower is better) | 0% | 0.1% | 0.1% | Better |
| Long-stay residents given anti-anxiety or sleep medication (lower is better) | 17.8% | 18.8% | 19.5% | Better |
| Long-stay residents with new or worse incontinence (lower is better) | 20.3% | 15.6% | 19% | Worse |
| Long-stay residents given a flu vaccine (higher is better) | 92.9% | 97.2% | 95.5% | Average |
| Long-stay residents given a pneumonia vaccine (higher is better) | 86.1% | 93% | 93.6% | Worse |
Short-stay residents
| Measure | This facility | New Jersey avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Short-stay residents newly given antipsychotic medication (lower is better) | 1.8% | 1.2% | 1.6% | Worse |
| Short-stay residents given a flu vaccine (higher is better) | 38.2% | 80.1% | 79.8% | Worse |
| Short-stay residents given a pneumonia vaccine (higher is better) | 67% | 79% | 82% | Worse |
Inspection citations
State inspectors cited this home for 26 health deficiencies and 11 fire safety deficiencies in the inspection records CMS currently publishes. 1 citation involved actual harm.
| Date | Citation | Severity | Status |
|---|---|---|---|
| June 25, 2025 Complaint | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Tag F0684 | D Potential harm, isolated | Corrected July 25, 2025 |
| March 7, 2025 Fire safety | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0914 | F Potential harm, widespread | Corrected March 8, 2025 |
| March 7, 2025 Fire safety | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Tag K0355 | F Potential harm, widespread | Corrected March 8, 2025 |
| March 7, 2025 Fire safety | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Tag K0712 | F Potential harm, widespread | Corrected March 8, 2025 |
| March 7, 2025 Standard | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Tag F0697 | G Actual harm, isolated | Corrected March 10, 2025 |
| March 7, 2025 Standard | 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. Nutrition and Dietary Deficiencies · Tag F0803 | E Potential harm, pattern | Corrected March 10, 2025 |
| March 7, 2025 Standard | Provide training in compliance and ethics. Administration Deficiencies · Tag F0946 | E Potential harm, pattern | Corrected March 10, 2025 |
| March 7, 2025 Standard | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Tag F0883 | E Potential harm, pattern | Corrected March 10, 2025 |
| March 7, 2025 Standard | Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Infection Control Deficiencies · Tag F0945 | E Potential harm, pattern | Corrected March 10, 2025 |
| March 7, 2025 Standard | Provide behavior health training consistent with the requirements and as determined by a facility assessment. Administration Deficiencies · Tag F0949 | E Potential harm, pattern | Corrected March 10, 2025 |
| March 7, 2025 Standard | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Tag F0692 | D Potential harm, isolated | Corrected March 10, 2025 |
| March 7, 2025 Standard | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Tag F0583 | D Potential harm, isolated | Corrected March 10, 2025 |
| March 7, 2025 Standard | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Tag F0580 | D Potential harm, isolated | Corrected March 10, 2025 |
| March 7, 2025 Standard | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | D Potential harm, isolated | Corrected March 10, 2025 |
| March 7, 2025 Standard | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Tag F0842 | D Potential harm, isolated | Corrected March 10, 2025 |
| March 7, 2025 Standard | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Tag F0757 | D Potential harm, isolated | Corrected March 10, 2025 |
| March 7, 2025 Standard | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Tag F0686 | D Potential harm, isolated | Corrected March 10, 2025 |
| January 5, 2024 Complaint | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | D Potential harm, isolated | Corrected January 26, 2024 |
| February 18, 2023 Fire safety | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Tag K0291 | F Potential harm, widespread | Corrected March 31, 2023 |
| February 18, 2023 Fire safety | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Tag K0345 | F Potential harm, widespread | Corrected March 31, 2023 |
| February 18, 2023 Fire safety | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Tag K0353 | F Potential harm, widespread | Corrected April 19, 2023 |
| February 18, 2023 Fire safety | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Tag K0712 | F Potential harm, widespread | Corrected March 31, 2023 |
| February 18, 2023 Fire safety | Have restrictions on the use of portable space heaters. Miscellaneous Deficiencies · Tag K0781 | E Potential harm, pattern | Corrected March 31, 2023 |
| February 18, 2023 Fire safety | Install an approved automatic sprinkler system. Smoke Deficiencies · Tag K0351 | E Potential harm, pattern | Corrected April 19, 2023 |
| February 18, 2023 Fire safety | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Tag K0363 | E Potential harm, pattern | Corrected March 31, 2023 |
| February 18, 2023 Fire safety | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Tag K0372 | E Potential harm, pattern | Corrected March 31, 2023 |
| February 18, 2023 Standard | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Tag F0812 | F Potential harm, widespread | Corrected March 31, 2023 |
| February 18, 2023 Standard | Plan the resident's discharge to meet the resident's goals and needs. Resident Assessment and Care Planning Deficiencies · Tag F0660 | D Potential harm, isolated | Corrected March 31, 2023 |
| February 18, 2023 Standard | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Tag F0656 | D Potential harm, isolated | Corrected March 31, 2023 |
| February 18, 2023 Standard | 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. Resident Rights Deficiencies · Tag F0578 | D Potential harm, isolated | Corrected March 31, 2023 |
| February 18, 2023 Standard | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Tag F0697 | D Potential harm, isolated | Corrected March 31, 2023 |
| February 18, 2023 Standard | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Tag F0755 | D Potential harm, isolated | Corrected March 31, 2023 |
| February 18, 2023 Standard | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Tag F0759 | D Potential harm, isolated | Corrected March 31, 2023 |
| February 18, 2023 Standard | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | D Potential harm, isolated | Corrected March 31, 2023 |
| March 8, 2021 Standard | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | D Potential harm, isolated | Corrected April 6, 2021 |
| March 8, 2021 Standard | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Tag F0812 | D Potential harm, isolated | Corrected March 19, 2021 |
| March 8, 2021 Standard | 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. Pharmacy Service Deficiencies · Tag F0761 | D Potential harm, isolated | Corrected March 19, 2021 |
Severity letters follow the CMS scope-and-severity grid: A–C no actual harm with potential for minimal harm; D–F potential for more than minimal harm; G–I actual harm; J–L immediate jeopardy to resident health or safety. How to read inspection citations.
Fines and payment denials
CMS reports 1 federal penalty in the past three years, including $3,595 in fines.
| Date | Penalty | Amount / length |
|---|---|---|
| March 7, 2025 | Fine | $3,595 |
Owners and managers
Individuals and organizations reported to CMS as owning or operating this nursing home.
| Name | Role | Share | Since |
|---|---|---|---|
| MILFORD MANOR HOLDCO LLC Organization | 5% or greater direct ownership interest | 100% | 12/27/2021 |
| PC GC HOLDCO LLC Organization | 5% or greater indirect ownership interest | — | 12/27/2021 |
| SMS 2021 TRUST Organization | 5% or greater indirect ownership interest | — | 12/27/2021 |
| AYDIN, EMMANUEL Individual | adp of the snf | NOT APPLICABLE | 12/27/2021 |
| MILFORD MANOR HOLDCO LLC Organization | adp of the snf | NOT APPLICABLE | 12/27/2021 |
| MILFORD MANOR PROPCO LLC Organization | adp of the snf | NOT APPLICABLE | 12/27/2021 |
| PC GC HOLDCO LLC Organization | adp of the snf | NOT APPLICABLE | 12/27/2021 |
| PEACE CAPITAL HOLDINGS LLC Organization | adp of the snf | NOT APPLICABLE | 12/27/2021 |
| REYES, GRACE Individual | adp of the snf | NOT APPLICABLE | 03/13/2023 |
| RUAYA, RIZZA Individual | adp of the snf | NOT APPLICABLE | 04/08/2025 |
| SMS 2021 TRUST Organization | adp of the snf | NOT APPLICABLE | 12/27/2021 |
| STEIN, SHALOM Individual | corporate officer | NOT APPLICABLE | 12/27/2021 |
| STEIN, SHALOM Individual | indirect ownership interest | NOT APPLICABLE | 12/27/2021 |
| STEIN, SHALOM Individual | managing control - governing body | NOT APPLICABLE | 12/27/2021 |
| AYDIN, EMMANUEL Individual | operational/managerial control | NOT APPLICABLE | 12/27/2021 |
| REYES, GRACE Individual | operational/managerial control | NOT APPLICABLE | 03/13/2023 |
| ZACKAI, RAANAN Individual | operational/managerial control | NOT APPLICABLE | 12/27/2021 |
| STEIN, SHALOM Individual | trustee of the snf | NOT APPLICABLE | 12/27/2021 |
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Frequently asked questions
What is Complete Care at Milford Manor LLC's rating?
Complete Care at Milford Manor LLC has 1 out of 5 stars on the CMS overall star rating. The average for New Jersey nursing homes is 3.3 stars.
How many inspection citations did Complete Care at Milford Manor LLC receive?
Its most recent standard health inspection found 13 citations, compared with a New Jersey average of 8.5. Every citation is listed on this page with its severity.
Does Complete Care at Milford Manor LLC accept Medicare and Medicaid?
CMS lists it as certified for: Medicare and Medicaid. Call the facility to confirm bed availability and whether it accepts your specific plan.
Who owns Complete Care at Milford Manor LLC?
It is for profit - corporation and part of Complete Care. The ownership section on this page lists the owners and managers reported to CMS.
Where is Complete Care at Milford Manor LLC and how do I contact it?
Complete Care at Milford Manor LLC is at 69 Maple Road, West Milford, NJ 07480. Phone: (973) 697-5640.
About this data
Ratings and measures come from the Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. They're based on state inspections, patient surveys and facility reports, and they describe the past. Facilities change, so visit in person and confirm details directly. About our data · Spotted an error? Let us know.