COMPLETE CARE AT MILFORD MANOR LLC
Open-data reference.
COMPLETE CARE AT MILFORD MANOR LLC is a for profit - corporation facility in WEST MILFORD, NJ with 120 certified beds and a 2-star overall CMS rating. The facility has 26 deficiency records on file. Total penalties: $4K.
69 MAPLE ROAD, WEST MILFORD, NJ 07480
Phone: 9736975640
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 315276
- Ownership
- For profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 120
- Residents
- 105
- In Hospital
- No
- County
- Passaic
- Last Inspection
- Mar 7, 2025
Staffing Data
- RN Hours
- 0.53 (nat'l avg: 0.68)
- LPN Hours
- 0.77
- CNA Hours
- 2.15
- Total Nursing Hours
- 3.45 (nat'l avg: 3.89)
- PT Hours
- 0.05
- Nursing Turnover
- 51.7%
- RN Turnover
- 66.7%
What the CMS Record Reveals About COMPLETE CARE AT MILFORD MANOR LLC
COMPLETE CARE AT MILFORD MANOR LLC operates 120 certified beds in WEST MILFORD, NJ with approximately 105 residents currently in care, and carries a CMS overall rating of 2 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (2★), staffing levels (2★), and quality measures (4★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 26 deficiency records from recent surveys, of which 1 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $4K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.45 total nursing hours per resident day (national average 3.89), with RN coverage at 0.53 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, COMPLETE CARE AT MILFORD MANOR LLC falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 51.7%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (26 most recent)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 25, 2025
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Category: Administration Deficiencies
Corrected: Mar 10, 2025
Provide training in compliance and ethics.
Category: Administration Deficiencies
Corrected: Mar 10, 2025
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Category: Infection Control Deficiencies
Corrected: Mar 10, 2025
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Mar 10, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Mar 10, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Mar 10, 2025
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.
Category: Nutrition and Dietary Deficiencies
Corrected: Mar 10, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category: Pharmacy Service Deficiencies
Corrected: Mar 10, 2025
Provide safe, appropriate pain management for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 10, 2025
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 10, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 10, 2025
Keep residents' personal and medical records private and confidential.
Category: Resident Rights Deficiencies
Corrected: Mar 10, 2025
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Mar 10, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jan 26, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Mar 31, 2023
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Mar 31, 2023
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Mar 31, 2023
Provide safe, appropriate pain management for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 31, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 31, 2023
Plan the resident's discharge to meet the resident's goals and needs.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Mar 31, 2023
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Mar 31, 2023
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.
Category: Resident Rights Deficiencies
Corrected: Mar 31, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Apr 6, 2021
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Mar 19, 2021
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.
Category: Pharmacy Service Deficiencies
Corrected: Mar 19, 2021
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 15.2% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 3.9% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.7% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 11.0% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 3.2% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 70.2% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 45.1% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.0% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 7.8% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 16.7% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 92.9% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 38.2% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 6.2% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 19.4% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 16.2% | Yes |
Penalty History 1 penalties totaling $4K
| Date | Type | Amount |
|---|---|---|
| Mar 7, 2025 | Fine | $4K |
Nearby Nursing Homes in NJ
ABIGAIL HOUSE FOR NURSING & REHABILITATION
CAMDEN, NJ
ABINGDON CARE & REHABILITATION CENTER
GREEN BROOK, NJ
ACCELERATE SKILLED NURSING AND REHAB PISCATAWAY
PISCATAWAY, NJ
ACCLAIM REHABILITATION AND NURSING CENTER
JERSEY CITY, NJ
ACTORS FUND HOME, THE
ENGLEWOOD, NJ
ADROIT CARE REHABILITATION AND NURSING CENTER
RAHWAY, NJ
Understanding Nursing Home Data
Related Data from Other Sources
Doctors Nearby
Find physicians and specialists in WEST MILFORD, NJ on PlainDoctor
Hospitals Nearby
Hospital quality ratings and safety data for WEST MILFORD, NJ on PlainHospital
Medicare Plans
Compare Medicare plans and coverage options near WEST MILFORD, NJ on PlainMedicare
County Health Data
Health outcomes, access, and quality metrics for Passaic on PlainHealth
Frequently Asked Questions
What is the overall CMS rating for COMPLETE CARE AT MILFORD MANOR LLC?
What are the staffing levels at COMPLETE CARE AT MILFORD MANOR LLC?
How many beds does COMPLETE CARE AT MILFORD MANOR LLC have?
Does COMPLETE CARE AT MILFORD MANOR LLC have any deficiencies on record?
Has COMPLETE CARE AT MILFORD MANOR LLC received any fines or penalties?
Who owns COMPLETE CARE AT MILFORD MANOR LLC?
When was COMPLETE CARE AT MILFORD MANOR LLC last inspected?
What quality measures are tracked for COMPLETE CARE AT MILFORD MANOR LLC?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.