Complete Care at Milford Manor LLC
Nursing Home · West Milford, NJ
CMS certification number315276
Contact & location
69 Maple RoadWest Milford, NJ 07480
Passaic County
- Phone
- (973) 697-5640
- ZIP code
- 07480 – all care providers
Facility details
- Certified beds
- 120
- Residents per day
- 111.7 (93% occupied)
- Ownership
- For profit - Corporation
- Chain
- Complete Care (85 facilities, avg 3.1★)
- Medicare certified since
- June 1, 1989
- Participates in
- Medicare and Medicaid
- Council
- Resident council
CMS star ratings
Staffing
Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.
- Total nurse staffing
- 2.97 (state 3.85 · U.S. 3.86)
- Registered nurses (RN)
- 0.42 (state 0.68 · U.S. 0.69)
- Licensed practical nurses
- 0.73 (state 0.93 · U.S. 0.86)
- Nurse aides
- 1.82 (state 2.23 · U.S. 2.32)
- Weekend total
- 2.44 (state 3.50 · U.S. 3.42)
- Nursing staff turnover
- 53.6 (state 39.7 · U.S. 45.8)%
- RN turnover
- 50.0 (state 37.7 · U.S. 42.9)%
- Administrators who left
- 1 in the last year
Inspections
- Last standard inspection
- March 7, 2025
- Health deficiencies (last cycle)
- 13.0 (state 8.8 · U.S. 9.3)
- From complaints
- 0
- Citations on record (3 years)
- 26 health · 11 fire safety · includes actual harm
| Date | Citation | Severity | Status |
|---|---|---|---|
| 2025-06-25 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. F0684 · Quality of Life and Care Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-07-25 |
| 2025-03-07 | Provide safe, appropriate pain management for a resident who requires such services. F0697 · Quality of Life and Care Deficiencies |
G Actual harm |
Corrected 2025-03-10 |
| 2025-03-07 | 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. F0803 · Nutrition and Dietary Deficiencies |
E No actual harm, potential for more than minimal harm |
Corrected 2025-03-10 |
| 2025-03-07 | Develop and implement policies and procedures for flu and pneumonia vaccinations. F0883 · Infection Control Deficiencies |
E No actual harm, potential for more than minimal harm |
Corrected 2025-03-10 |
| 2025-03-07 | Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. F0945 · Infection Control Deficiencies |
E No actual harm, potential for more than minimal harm |
Corrected 2025-03-10 |
| 2025-03-07 | Provide training in compliance and ethics. F0946 · Administration Deficiencies |
E No actual harm, potential for more than minimal harm |
Corrected 2025-03-10 |
| 2025-03-07 | Provide behavior health training consistent with the requirements and as determined by a facility assessment. F0949 · Administration Deficiencies |
E No actual harm, potential for more than minimal harm |
Corrected 2025-03-10 |
| 2025-03-07 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. F0580 · Resident Rights Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-03-10 |
| 2025-03-07 | Keep residents' personal and medical records private and confidential. F0583 · Resident Rights Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-03-10 |
| 2025-03-07 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. F0686 · Quality of Life and Care Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-03-10 |
| 2025-03-07 | Provide enough food/fluids to maintain a resident's health. F0692 · Quality of Life and Care Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-03-10 |
| 2025-03-07 | Ensure each resident’s drug regimen must be free from unnecessary drugs. F0757 · Pharmacy Service Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-03-10 |
| 2025-03-07 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. F0842 · Resident Assessment and Care Planning Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-03-10 |
| 2025-03-07 | Provide and implement an infection prevention and control program. F0880 · Infection Control Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-03-10 |
| 2024-01-05 | Provide and implement an infection prevention and control program. F0880 · Infection Control Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-01-26 |
| 2023-02-18 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812 · Nutrition and Dietary Deficiencies |
F No actual harm, potential for more than minimal harm |
Corrected 2023-03-31 |
| 2023-02-18 | 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. F0578 · Resident Rights Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2023-03-31 |
| 2023-02-18 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656 · Resident Assessment and Care Planning Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2023-03-31 |
| 2023-02-18 | Plan the resident's discharge to meet the resident's goals and needs. F0660 · Resident Assessment and Care Planning Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2023-03-31 |
| 2023-02-18 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689 · Quality of Life and Care Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2023-03-31 |
| 2023-02-18 | Provide safe, appropriate pain management for a resident who requires such services. F0697 · Quality of Life and Care Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2023-03-31 |
| 2023-02-18 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. F0755 · Pharmacy Service Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2023-03-31 |
| 2023-02-18 | Ensure medication error rates are not 5 percent or greater. F0759 · Pharmacy Service Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2023-03-31 |
| 2021-03-08 | 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. F0761 · Pharmacy Service Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2021-03-19 |
| 2021-03-08 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812 · Nutrition and Dietary Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2021-03-19 |
| 2021-03-08 | Provide and implement an infection prevention and control program. F0880 · Infection Control Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2021-04-06 |
Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results
Fines & penalties
1 penalty in the last three years, including $3,595 in fines.
| Date | Type | Amount |
|---|---|---|
| 2025-03-07 | Fine | $3,595 |
Ownership & management
| Name | Role | Since |
|---|---|---|
| Milford Manor Holdco LLC (organization) | 5%+ Direct Ownership Interest · 100% | |
| PC GC Holdco LLC (organization) | 5%+ Indirect Ownership Interest | |
| SMS 2021 Trust (organization) | 5%+ Indirect Ownership Interest | |
| Aydin, Emmanuel (individual) | Administrator · NOT APPLICABLE | |
| Milford Manor Holdco LLC (organization) | Administrator · NOT APPLICABLE | |
| Milford Manor Propco LLC (organization) | Administrator · NOT APPLICABLE | |
| PC GC Holdco LLC (organization) | Administrator · NOT APPLICABLE | |
| Peace Capital Holdings LLC (organization) | Administrator · NOT APPLICABLE | |
| Reyes, Grace (individual) | Administrator · NOT APPLICABLE | |
| Ruaya, Rizza (individual) | Administrator · NOT APPLICABLE | |
| SMS 2021 Trust (organization) | Administrator · NOT APPLICABLE | |
| Stein, Shalom (individual) | Corporate Officer · NOT APPLICABLE | |
| Stein, Shalom (individual) | Indirect Ownership Interest · NOT APPLICABLE | |
| Stein, Shalom (individual) | Managing Control - Governing Body · NOT APPLICABLE | |
| Aydin, Emmanuel (individual) | Operational/managerial Control · NOT APPLICABLE | |
| Reyes, Grace (individual) | Operational/managerial Control · NOT APPLICABLE | |
| Zackai, Raanan (individual) | Operational/managerial Control · NOT APPLICABLE | |
| Stein, Shalom (individual) | Trustee Of The Snf · NOT APPLICABLE |
Frequently asked questions
What is the rating of Complete Care at Milford Manor LLC?
Complete Care at Milford Manor LLC has a 1-star overall rating from the Centers for Medicare & Medicaid Services on a scale of 1 to 5, compared with a 3.3-star average in New Jersey.
How many beds does Complete Care at Milford Manor LLC have?
It has 120 certified beds and cares for about 112 residents per day.
Has Complete Care at Milford Manor LLC been fined?
Yes. CMS lists 1 penalty totaling $3,595 in the last three years.
Who owns Complete Care at Milford Manor LLC?
It is part of Complete Care and is classified as for profit - corporation. See the ownership table above for all owners and managers reported to CMS.
What is the phone number of Complete Care at Milford Manor LLC?
(973) 697-5640. The facility is located at 69 Maple Road, West Milford, NJ 07480.
Source: CMS Care Compare, August 2026. Information is provided as published by CMS; verify details directly with the facility.