West Milford, NJ

Complete Care At Milford Manor LLC

2-star overall rating with 2-star inspections with $3,595 in total fines with 14 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

69 Maple Road, West Milford, NJ

(973) 697-5640

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

105

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Complete Care

Operator or chain grouping

Approved since

1989-06-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.53

Registered nurse staffing

LPN hours / resident day

0.77

Licensed practical nurse staffing

Aide hours / resident day

2.15

Nurse aide staffing

Weekend hours

2.84

Weekend nurse staffing

RN turnover

67%

Annual RN turnover

Total nurse turnover

52%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	3.0	2.1 0.9 pts worse	1.9 1.1 pts worse	Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days	1.6	1.1 0.5 pts worse	1.8 0.2 pts better	Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	70.2%	93.0% 22.8 pts worse	93.4% 23.2 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	92.9%	97.2% 4.3 pts worse	95.5% 2.6 pts worse	Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury	3.2%	2.4% 0.8 pts worse	3.3% 0.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	11.0%	11.4% 0.4 pts better	11.4% 0.4 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	3.9%	4.6% 0.7 pts better	5.4% 1.5 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	16.7%	19.0% 2.3 pts better	19.6% 2.9 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	16.2%	13.5% 2.7 pts worse	16.7% 0.5 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened	7.8%	9.8% 2 pts better	16.3% 8.5 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	15.2%	9.7% 5.5 pts worse	14.9% 0.3 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.7%	0.7% About the same	1.0% 0.3 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	0.0%	0.8% 0.8 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	19.4%	15.9% 3.5 pts worse	19.8% 0.4 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	6.2%	6.0% 0.2 pts worse	5.1% 1.1 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	45.1%	78.7% 33.6 pts worse	81.7% 36.6 pts worse	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit	9.5%	8.2% 1.3 pts worse	12.0% 2.5 pts better	Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.2% 1.2 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	38.2%	80.1% 41.9 pts worse	79.7% 41.5 pts worse	Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission	28.4%	25.4% 3 pts worse	23.9% 4.5 pts worse	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-03-07 · Fire 2025-03-07

14 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 2 Health 2023-02-18 · Fire 2023-02-18

8 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

8 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 3 Health 2021-03-08 · Fire 2021-03-08

4 health deficiencies

Top issue: Infection Control (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-03-07

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-03-08

F · Potential for more than minimal harm 2025-03-07

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-03-08

F · Potential for more than minimal harm 2025-03-07

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2025-03-08

F · Potential for more than minimal harm 2023-02-18

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2023-03-31

F · Potential for more than minimal harm 2023-02-18

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-03-31

F · Potential for more than minimal harm 2023-02-18

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-04-19

F · Potential for more than minimal harm 2023-02-18

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-03-31

E · Potential for more than minimal harm 2023-02-18

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-04-19

E · Potential for more than minimal harm 2023-02-18

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-03-31

E · Potential for more than minimal harm 2023-02-18

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-03-31

E · Potential for more than minimal harm 2023-02-18

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2023-03-31

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-06-25

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-07-25

G · Actual harm 2025-03-07

F697 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-03-10

E · Potential for more than minimal harm 2025-03-07

F803 · Nutrition and Dietary Deficiencies

Health

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.

Corrected 2025-03-10

E · Potential for more than minimal harm 2025-03-07

F883 · Infection Control Deficiencies

Health

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

Corrected 2025-03-10

E · Potential for more than minimal harm 2025-03-07

F945 · Infection Control Deficiencies

Health

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Corrected 2025-03-10

E · Potential for more than minimal harm 2025-03-07

F946 · Administration Deficiencies

Health

Provide training in compliance and ethics.

Corrected 2025-03-10

E · Potential for more than minimal harm 2025-03-07

F949 · Administration Deficiencies

Health

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

Corrected 2025-03-10

D · Potential for more than minimal harm 2025-03-07

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2025-03-10

D · Potential for more than minimal harm 2025-03-07

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2025-03-10

D · Potential for more than minimal harm 2025-03-07

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-03-10

D · Potential for more than minimal harm 2025-03-07

F692 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-03-10

D · Potential for more than minimal harm 2025-03-07

F757 · Pharmacy Service Deficiencies

Health

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

Corrected 2025-03-10

D · Potential for more than minimal harm 2025-03-07

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-03-10

D · Potential for more than minimal harm 2025-03-07

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-10

D · Potential for more than minimal harm 2024-01-05

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-01-26

F · Potential for more than minimal harm 2023-02-18

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2023-03-31