Federal inspection record · CMS data as of October 1, 2026
Complete Care At Milford Manor LLC
69 Maple Road, West Milford, NJ · (973) 697-5640
- Certified beds
- 120
- Residents per day
- 114
- Ownership
- For-Profit
- Chain
- Complete Care
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- June 1, 1989
1
How this home got 2 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in New Jersey.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★2 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among New Jersey homes
Complete Care At Milford Manor LLC carries 79 inspection points. That is fewer than 30% of New Jersey's 346 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in New Jersey: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–18 pts
- 4★ 18–37 pts
- 3★ 37–60 pts
- 2★ 60–93.75 pts
- 1★ over 93.75 pts
Bars show every rated home in New Jersey by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
26 health citations on record since 2021. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (1)
-
G
Provide safe, appropriate pain management for a resident who requires such services.
Everything else, by area of care
Quality of Life and Care5D
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide enough food/fluids to maintain a resident's health.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Infection Control5E
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- E
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
- D
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
Pharmacy Service4D
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure medication error rates are not 5 percent or greater.
- D
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.
Nutrition and Dietary3F
- E
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.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Resident Rights3D
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- D
Keep residents' personal and medical records private and confidential.
- D
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 Assessment and Care Planning3D
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Plan the resident's discharge to meet the resident's goals and needs.
Administration2E
- E
Provide training in compliance and ethics.
- E
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Inspection history
2025-03-07
13 health deficiencies · 3 fire-safety deficiencies
Top issue: Infection Control (3 deficiencies)
2023-02-18
9 health deficiencies · 8 fire-safety deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2021-03-08
4 health deficiencies · 0 fire-safety deficiencies
Top issue: Infection Control (2 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 5 min of nursing staff time a day, 33 min of it from a registered nurse.
This home
3 h 5 min
New Jersey average
3 h 54 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 53% of nursing staff and 50% of registered nurses left in the past year, along with 1 administrator.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$3,595 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-03-07 | Fine | $3,595 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.2 pts worse | 2.2 | 2.0 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.6 pts worse | 1.6 | 1.0 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine3.6 pts worse | 89.4% | 93.0% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine3.2 pts better | 100.0% | 96.8% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury0.2 pts worse | 2.5% | 2.3% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms16.6 pts worse | 29.1% | 12.5% | 13.5% |
| Percentage of long-stay residents who lose too much weight2.8 pts better | 1.9% | 4.7% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication0.9 pts worse | 19.7% | 18.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication1.5 pts worse | 14.4% | 12.9% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened0.8 pts better | 6.5% | 7.3% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased1.1 pts worse | 9.4% | 8.3% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.5 pts better | 0.0% | 0.5% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.1 pts better | 0.6% | 0.7% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence4.2 pts worse | 19.4% | 15.2% | 18.3% |
| Percentage of long-stay residents with pressure ulcers2.1 pts better | 3.2% | 5.3% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine0.6 pts better | 79.6% | 79.0% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit4 pts worse | 12.1% | 8.1% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.8 pts worse | 1.9% | 1.1% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine4.1 pts better | 83.6% | 79.5% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission4.9 pts better | 19.2% | 24.1% | 23.4% |
·
Who owns and runs it
18 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Milford Manor Holdco LLC | 5% Or Greater Direct Ownership Interest · Organization | 100% | 1 facilities |
| Aydin, Emmanuel | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Aydin, Emmanuel | Adp Of The SNF · Individual | 0% | 1 facilities |
| Milford Manor Holdco LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| Milford Manor Propco LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| Pc Gc Holdco LLC | 5% Or Greater Indirect Ownership Interest · Organization | 0% | 2 facilities |
| Pc Gc Holdco LLC | Adp Of The SNF · Organization | 0% | 2 facilities |
| Peace Capital Holdings LLC | Adp Of The SNF · Organization | 0% | 46 facilities |
| Reyes, Grace | Operational/Managerial Control · Individual | 0% | 2 facilities |
| Reyes, Grace | Adp Of The SNF · Individual | 0% | 2 facilities |
| Ruaya, Rizza | Adp Of The SNF · Individual | 0% | 1 facilities |
| Sms 2021 Trust | 5% Or Greater Indirect Ownership Interest · Organization | 0% | 77 facilities |
| Sms 2021 Trust | Adp Of The SNF · Organization | 0% | 77 facilities |
| Stein, Shalom | Indirect Ownership Interest · Individual | 0% | 87 facilities |
| Stein, Shalom | Managing Control - Governing Body · Individual | 0% | 87 facilities |
| Stein, Shalom | Corporate Officer · Individual | 0% | 87 facilities |
| Stein, Shalom | Trustee Of The SNF · Individual | 0% | 87 facilities |
| Zackai, Raanan | Operational/Managerial Control · Individual | 0% | 3 facilities |
·
Fire safety
11 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke6F
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
- E
Install an approved automatic sprinkler system.
- E
Install corridor and hallway doors that block smoke.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Miscellaneous3F
- F
Have simulated fire drills held at unexpected times.
- F
Have simulated fire drills held at unexpected times.
- E
Have restrictions on the use of portable space heaters.
Gas, Vacuum, and Electrical Systems1F
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Egress1F
- F
Install emergency lighting that can last at least 1 1/2 hours.
·
Other homes nearby
-
Health Center At Bloomingdale
Bloomingdale, NJ · Continuum Healthcare
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 3 h 17 min
- Fines
- $0
-
Lakeland Nursing & Rehab
Haskell, NJ · Best Care Services
★★★★★- Worst citation, 3 yrs
- D
- Nursing / resident / day
- 3 h 43 min
- Fines
- $0
-
Phoenix Center For Rehabilitation And Pediatrics
Haskell, NJ · Philosophy Care Centers
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 4 h 25 min
- Fines
- $0