COMPLETE CARE AT MILFORD MANOR LLC
69 MAPLE ROAD, WEST MILFORD, NJ 07480 · CCN 315276
Ratings
- Overall
- ★★☆☆☆ 2
- Health inspection
- ★★☆☆☆ 2
- Quality measures
- ★★★★☆ 4
- Staffing
- ★★☆☆☆ 2
Facility
- Ownership type
- For profit - Corporation
- Certified beds
- 120
- Avg residents/day
- 104.9
- Phone
- 9736975640
Inspection history vs New Jersey & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | New Jersey avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2025-03-07 | 14 | 8.6 | 9.5 | +5.4 worse |
| 2 | 2023-02-18 | 8 | 8.0 | 9.8 | at state average |
| 3 | 2021-03-08 | 4 | 4.9 | 9.3 | -0.9 better |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Quality of life and care | 4 |
| Resident assessment and care planning | 1 |
| Resident rights | 2 |
| Nutrition and dietary | 1 |
| Pharmacy service | 1 |
| Administration | 2 |
| Infection control | 3 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 3.45 | 51.7% |
| RN staffing (reported) | 0.53 | 66.7% |
| Total nurse staffing (adjusted) | 3.56 | — |
Fines & penalties
- Total fines
- $3,595
- Number of fines
- 1
- Number of penalties
- 1
- Payment denials
- 0
Chain
- Chain
- COMPLETE CARE
- Facilities in chain
- 85
- Chain avg overall
- 3.20 / 5
Inspection citations (26)1 actual harm
- DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-06-25 · Health · corrected 2025-07-25
Potential for more than minimal harm
- DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2025-03-07 · Health · corrected 2025-03-10
Potential for more than minimal harm
- DF0583Keep residents' personal and medical records private and confidential.2025-03-07 · Health · corrected 2025-03-10
Potential for more than minimal harm
- DF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2025-03-07 · Health · corrected 2025-03-10
Potential for more than minimal harm
- DF0692Provide enough food/fluids to maintain a resident's health.2025-03-07 · Health · corrected 2025-03-10
Potential for more than minimal harm
- GF0697Provide safe, appropriate pain management for a resident who requires such services.2025-03-07 · Health · corrected 2025-03-10
Actual harm
- DF0757Ensure each resident’s drug regimen must be free from unnecessary drugs.2025-03-07 · Health · corrected 2025-03-10
Potential for more than minimal harm
- EF0803Ensure 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.2025-03-07 · Health · corrected 2025-03-10
Potential for more than minimal harm
- DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2025-03-07 · Health · corrected 2025-03-10
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2025-03-07 · Health · corrected 2025-03-10
Potential for more than minimal harm
- EF0883Develop and implement policies and procedures for flu and pneumonia vaccinations.2025-03-07 · Health · corrected 2025-03-10
Potential for more than minimal harm
- EF0945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.2025-03-07 · Health · corrected 2025-03-10
Potential for more than minimal harm
- EF0946Provide training in compliance and ethics.2025-03-07 · Health · corrected 2025-03-10
Potential for more than minimal harm
- EF0949Provide behavior health training consistent with the requirements and as determined by a facility assessment.2025-03-07 · Health · corrected 2025-03-10
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2024-01-05 · Health · corrected 2024-01-26
Potential for more than minimal harm
- DF0578Honor 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.2023-02-18 · Health · corrected 2023-03-31
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2023-02-18 · Health · corrected 2023-03-31
Potential for more than minimal harm
- DF0660Plan the resident's discharge to meet the resident's goals and needs.2023-02-18 · Health · corrected 2023-03-31
Potential for more than minimal harm
- DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-02-18 · Health · corrected 2023-03-31
Potential for more than minimal harm
- DF0697Provide safe, appropriate pain management for a resident who requires such services.2023-02-18 · Health · corrected 2023-03-31
Potential for more than minimal harm
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2023-02-18 · Health · corrected 2023-03-31
Potential for more than minimal harm
- DF0759Ensure medication error rates are not 5 percent or greater.2023-02-18 · Health · corrected 2023-03-31
Potential for more than minimal harm
- FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2023-02-18 · Health · corrected 2023-03-31
Potential for more than minimal harm
- DF0761Ensure 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.2021-03-08 · Health · corrected 2021-03-19
Potential for more than minimal harm
- DF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2021-03-08 · Health · corrected 2021-03-19
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2021-03-08 · Health · corrected 2021-04-06
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| MILFORD MANOR HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | 2021-12-27 |
| PC GC HOLDCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2021-12-27 |
| PEACE CAPITAL HOLDINGS LLC (DE) | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2021-12-27 |
| SMS 2021 TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2021-12-27 |
| AYDIN, EMMANUEL | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2021-12-27 |
| REYES, GRACE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2023-03-13 |
| ZACKAI, RAANAN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2021-12-27 |
| STEIN, SHALOM | Individual | CORPORATE OFFICER | — | 2021-12-27 |
Other facilities in WEST MILFORD
| Name | Overall | Beds |
|---|
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.