C74

COMPLETE CARE AT MILFORD MANOR LLC

Grade C 74/100 composite score

For profit - Corporation

CMS Star Ratings

Overall
2/5
Health Insp.
2/5
Quality
4/5
Staffing
2/5
RN Staffing
Not rated

Certified Beds

120

Ownership

For profit - Corporation

Total Fines

$3,595

Last Survey

N/A

69 MAPLE ROAD, WEST MILFORD, NJ 07480
9736975640

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.54h
LPN
0.79h
CNA
2.22h
Total
3.56h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

MILFORD MANOR HOLDCO LLC

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Dec 2021

100%

PC GC HOLDCO LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Dec 2021

PEACE CAPITAL HOLDINGS LLC (DE)

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Dec 2021

SMS 2021 TRUST

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Dec 2021

AYDIN, EMMANUEL

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Dec 2021

REYES, GRACE

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Mar 2023

ZACKAI, RAANAN

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Dec 2021

STEIN, SHALOM

IndividualCORPORATE OFFICERSince Dec 2021

Penalties & Fines (1)

$3,595total fines
DateTypeDescriptionAmount
Mar 7, 2025Fine$3,595

Health Inspection Deficiencies (26)

June 25, 2025Health1 deficiency
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Jul 25, 2025
March 7, 2025Health13 deficiencies1 severe
0580DMinimal harm, Isolated

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

Corrected Mar 10, 2025
0686DMinimal harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Mar 10, 2025
0692DMinimal harm, Isolated

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Corrected Mar 10, 2025
0697GActual harm, Isolated

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Mar 10, 2025
0757DMinimal harm, Isolated

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Pharmacy Service Deficiencies

Corrected Mar 10, 2025
0803EMinimal harm, Pattern

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

Corrected Mar 10, 2025
0842DMinimal harm, Isolated

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

Corrected Mar 10, 2025
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Mar 10, 2025
0883EMinimal harm, Pattern

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Infection Control Deficiencies

Corrected Mar 10, 2025
0946EMinimal harm, Pattern

Provide training in compliance and ethics.

Administration Deficiencies

Corrected Mar 10, 2025
0583DMinimal harm, Isolated

Keep residents' personal and medical records private and confidential.

Resident Rights Deficiencies

Corrected Mar 10, 2025
0945EMinimal harm, Pattern

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

Corrected Mar 10, 2025
0949EMinimal harm, Pattern

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Administration Deficiencies

Corrected Mar 10, 2025
January 5, 2024Health1 deficiency
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Jan 26, 2024
February 18, 2023Health8 deficiencies
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Mar 31, 2023
0697DMinimal harm, Isolated

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Mar 31, 2023
0578DMinimal harm, Isolated

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

Corrected Mar 31, 2023
0656DMinimal harm, Isolated

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

Corrected Mar 31, 2023
0660DMinimal harm, Isolated

Plan the resident's discharge to meet the resident's goals and needs.

Resident Assessment and Care Planning Deficiencies

Corrected Mar 31, 2023
0755DMinimal harm, Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Mar 31, 2023
0759DMinimal harm, Isolated

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Corrected Mar 31, 2023
0812FMinimal harm, Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Mar 31, 2023
March 8, 2021Health3 deficiencies
0761DMinimal harm, Isolated

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

Corrected Mar 19, 2021
0812DMinimal harm, Isolated

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Mar 19, 2021
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Apr 6, 2021

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Frequently Asked Questions

What is the CareGrader rating for COMPLETE CARE AT MILFORD MANOR LLC?

COMPLETE CARE AT MILFORD MANOR LLC in WEST MILFORD, New Jersey has a CareGrader grade of C (Average), with a composite score of 73.8 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for COMPLETE CARE AT MILFORD MANOR LLC?

COMPLETE CARE AT MILFORD MANOR LLC has an overall CMS star rating of 2 out of 5, a health inspection rating of 2/5, and a staffing rating of 2/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does COMPLETE CARE AT MILFORD MANOR LLC have?

COMPLETE CARE AT MILFORD MANOR LLC has 26 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

Has COMPLETE CARE AT MILFORD MANOR LLC been fined?

Yes. COMPLETE CARE AT MILFORD MANOR LLC has $3,595 in total fines from CMS enforcement actions across 1 penalty.

How many beds does COMPLETE CARE AT MILFORD MANOR LLC have?

COMPLETE CARE AT MILFORD MANOR LLC has 120 certified beds with approximately 104 current residents (87% occupancy). The facility is located at 69 MAPLE ROAD, WEST MILFORD, New Jersey 07480. It is a for profit - corporation facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.