Starfile

Starfile / New Jersey

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.

CycleInspection dateThis facilityNew Jersey avgNational avgvs state
12025-03-07148.69.5+5.4 worse
22023-02-1888.09.8at state average
32021-03-0844.99.3-0.9 better

Cycle 1 deficiencies by category

CategoryDeficiencies
Quality of life and care4
Resident assessment and care planning1
Resident rights2
Nutrition and dietary1
Pharmacy service1
Administration2
Infection control3

Staffing (hours per resident per day)

MetricThis facilityTurnover
Total nurse staffing (reported)3.4551.7%
RN staffing (reported)0.5366.7%
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

  1. 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

  2. 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

  3. DF0583Keep residents' personal and medical records private and confidential.2025-03-07 · Health · corrected 2025-03-10

    Potential for more than minimal harm

  4. 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

  5. DF0692Provide enough food/fluids to maintain a resident's health.2025-03-07 · Health · corrected 2025-03-10

    Potential for more than minimal harm

  6. GF0697Provide safe, appropriate pain management for a resident who requires such services.2025-03-07 · Health · corrected 2025-03-10

    Actual harm

  7. 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

  8. 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

  9. 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

  10. DF0880Provide and implement an infection prevention and control program.2025-03-07 · Health · corrected 2025-03-10

    Potential for more than minimal harm

  11. 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

  12. 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

  13. EF0946Provide training in compliance and ethics.2025-03-07 · Health · corrected 2025-03-10

    Potential for more than minimal harm

  14. 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

  15. DF0880Provide and implement an infection prevention and control program.2024-01-05 · Health · corrected 2024-01-26

    Potential for more than minimal harm

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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

  22. DF0759Ensure medication error rates are not 5 percent or greater.2023-02-18 · Health · corrected 2023-03-31

    Potential for more than minimal harm

  23. 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

  24. 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

  25. 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

  26. DF0880Provide and implement an infection prevention and control program.2021-03-08 · Health · corrected 2021-04-06

    Potential for more than minimal harm

Ownership

OwnerTypeRolePercentSince
MILFORD MANOR HOLDCO LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%2021-12-27
PC GC HOLDCO LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST2021-12-27
PEACE CAPITAL HOLDINGS LLC (DE)Organization5% OR GREATER INDIRECT OWNERSHIP INTEREST2021-12-27
SMS 2021 TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST2021-12-27
AYDIN, EMMANUELIndividualOPERATIONAL/MANAGERIAL CONTROL2021-12-27
REYES, GRACEIndividualOPERATIONAL/MANAGERIAL CONTROL2023-03-13
ZACKAI, RAANANIndividualOPERATIONAL/MANAGERIAL CONTROL2021-12-27
STEIN, SHALOMIndividualCORPORATE OFFICER2021-12-27

Other facilities in WEST MILFORD

NameOverallBeds

Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.