New Jersey › Passaic County › West Milford
Complete Care At Milford Manor LLC
69 Maple Road, West Milford, NJ 07480
Ratings are based on the most recent data available; a facility's ratings may have changed since the last update. The health inspection rating is based on the three most recent standard surveys and complaint investigations. CMS processed this record on 1 Aug 2026. View the Care Compare record.
Complete Care At Milford Manor LLC is a For-profit, corporation nursing home in West Milford, New Jersey, certified for 120 beds and caring for about 112 residents a day.
CMS gives it 1 of 5 stars overall, below the New Jersey median of 4; the health inspection rating is 2, staffing 1 and quality measures 4.
Inspectors recorded 26 health deficiencies across the three most recent survey cycles (13, 9, 4 by cycle, most recent first), 1 of them at the actual-harm or immediate-jeopardy level. That is 21.7 per 100 beds, more than the state median of 15.2.
CMS lists 1 penalty in the period covered: fines totalling $4K.
Reported nurse staffing is 3.0 hours per resident per day (0.4 RN), close to the New Jersey median of 3.6; nursing staff turnover is 53.6%.
Compared with county, state and nation
| Measure | This facility | Passaic Co. median | New Jersey median | US average |
|---|---|---|---|---|
| Overall star rating | 1 | 3 | 4 | 3.0 |
| Health citations, 3 cycles | 26 | 24 | 21 | 28.7 |
| Citations per 100 beds | 21.7 | 14.4 | 15.2 | 26.8 |
| Total nurse hours per resident day | 3.0 | 3.5 | 3.6 | 3.9 |
| RN hours per resident day | 0.4 | 0.6 | 0.5 | 0.7 |
| Nursing staff turnover | 53.6% | 41.6% | 38.9% | 45.8% |
| Fines listed | $3,595 | $3,595 | $0 | — |
County and state figures are medians across facilities (19 in the county, 348 in the state); the US column is the CMS national average where CMS publishes one.
Citations by survey cycle
Dark bar: this facility. Grey bar: New Jersey average per facility for the same cycle, as published by CMS. Standard health survey dates: 7 Mar 2025, 18 Feb 2023.
Severity mix: G ×1 D ×19 E ×5 F ×1
Health deficiencies
Every health citation in the current CMS record (three survey cycles), most recent first. Tag text is the CMS requirement summary, not the inspection narrative.
Scope and severity letters (A–L)
| Survey date | Tag | What the tag requires | Severity | Type | Corrected |
|---|---|---|---|---|---|
| 25 Jun 2025 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint investigation | 25 Jul 2025 |
| 7 Mar 2025 | F0697 | Provide safe, appropriate pain management for a resident who requires such services. | G | Standard survey | 10 Mar 2025 |
| 7 Mar 2025 | F0803 | 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. | E | Standard survey | 10 Mar 2025 |
| 7 Mar 2025 | F0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | E | Standard survey | 10 Mar 2025 |
| 7 Mar 2025 | F0945 | Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | E | Standard survey | 10 Mar 2025 |
| 7 Mar 2025 | F0946 | Provide training in compliance and ethics. | E | Standard survey | 10 Mar 2025 |
| 7 Mar 2025 | F0949 | Provide behavior health training consistent with the requirements and as determined by a facility assessment. | E | Standard survey | 10 Mar 2025 |
| 7 Mar 2025 | F0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | Standard survey | 10 Mar 2025 |
| 7 Mar 2025 | F0583 | Keep residents' personal and medical records private and confidential. | D | Standard survey | 10 Mar 2025 |
| 7 Mar 2025 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Standard survey | 10 Mar 2025 |
| 7 Mar 2025 | F0692 | Provide enough food/fluids to maintain a resident's health. | D | Standard survey | 10 Mar 2025 |
| 7 Mar 2025 | F0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D | Standard survey | 10 Mar 2025 |
| 7 Mar 2025 | F0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | Standard survey | 10 Mar 2025 |
| 7 Mar 2025 | F0880 | Provide and implement an infection prevention and control program. | D | Standard survey | 10 Mar 2025 |
| 5 Jan 2024 | F0880 | Provide and implement an infection prevention and control program. | D | Complaint investigation | 26 Jan 2024 |
| 18 Feb 2023 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Standard survey | 31 Mar 2023 |
| 18 Feb 2023 | F0578 | 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. | D | Standard survey | 31 Mar 2023 |
| 18 Feb 2023 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Standard survey | 31 Mar 2023 |
| 18 Feb 2023 | F0660 | Plan the resident's discharge to meet the resident's goals and needs. | D | Standard survey | 31 Mar 2023 |
| 18 Feb 2023 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard survey | 31 Mar 2023 |
| 18 Feb 2023 | F0697 | Provide safe, appropriate pain management for a resident who requires such services. | D | Standard survey | 31 Mar 2023 |
| 18 Feb 2023 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Standard survey | 31 Mar 2023 |
| 18 Feb 2023 | F0759 | Ensure medication error rates are not 5 percent or greater. | D | Standard survey | 31 Mar 2023 |
| 8 Mar 2021 | F0761 | 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. | D | Standard survey | 19 Mar 2021 |
| 8 Mar 2021 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | D | Standard survey | 19 Mar 2021 |
| 8 Mar 2021 | F0880 | Provide and implement an infection prevention and control program. | D | Standard survey | 6 Apr 2021 |
Penalties
| Date | Type | Amount | Detail |
|---|---|---|---|
| 7 Mar 2025 | Fine | $3,595 |
Staffing
Hours per resident per day as reported through the Payroll-Based Journal; grey bars are the New Jersey average. Turnover: nursing staff 53.6%, RNs 50.0%; 1 administrator left in the reporting year.
Quality measures
| Measure | Residents | This facility | New Jersey median | US median |
|---|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 14.0% | 7.3% | 12.6% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | 0.2% | 0.3% |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.6% | 0.4% | 0.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 2.9% | 2.0% | 2.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 1.8% | 0.9% | 1.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 7.0% | 6.6% | 12.5% |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 2.6% | 4.8% | 4.2% |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 14.9% | 11.8% | 13.4% |
Four-quarter averages for the measures CMS uses in the quality-measure star rating (2025Q2-2026Q1). Lower is better for every measure listed. Medians are computed across facilities on this site.
Ownership
Ownership type: for-profit, corporation. Chain: Complete Care (85 facilities).
| Organisation | Role in the CMS record | Interest | Since |
|---|---|---|---|
| Milford Manor Holdco LLC | 5% or greater direct ownership interest | 100% | 12/27/2021 |
| Pc Gc Holdco LLC | 5% or greater indirect ownership interest | NO PERCENTAGE PROVIDED | 12/27/2021 |
| Milford Manor Holdco LLC | Adp of the snf | NOT APPLICABLE | 12/27/2021 |
| Milford Manor Propco LLC | Adp of the snf | NOT APPLICABLE | 12/27/2021 |
| Pc Gc Holdco LLC | Adp of the snf | NOT APPLICABLE | 12/27/2021 |
| Peace Capital Holdings LLC | Adp of the snf | NOT APPLICABLE | 12/27/2021 |
Only organisations are shown. CMS also records individual owners, officers and managing employees; this site does not publish people's names.
Other nursing homes in Passaic County
| Facility | City | Beds | Overall | Health | Staffing | Citations | Per 100 beds | Fines | Last survey |
|---|---|---|---|---|---|---|---|---|---|
| Careone At Wayne | Wayne | 101 | 5 | 5 | 3 | 8 | 7.9 | — | 23 Dec 2025 |
| Complete Care At Hamilton, LLC | Passaic | 120 | 5 | 4 | 5 | 24 | 20.0 | $25K | 9 Sep 2025 |
| Doctors Subacute Healthcare, LLC | Paterson | 54 | 5 | 4 | 4 | 16 | 29.6 | — | 2 Dec 2025 |
| Health Center At Bloomingdale | Bloomingdale | 120 | 5 | 4 | 4 | 28 | 23.3 | — | 28 Aug 2025 |
| Atrium Post Acute Care of Wayne | Wayne | 209 | 4 | 4 | 3 | 21 | 10.0 | $3K | 25 Feb 2025 |
| Barnert Subacute Rehabilitation Center, LLC | Paterson | 68 | 4 | 4 | 3 | 13 | 19.1 | — | 23 Apr 2025 |
| Lakeland Nursing & Rehab | Haskell | 201 | 4 | 3 | 3 | 23 | 11.4 | — | 29 Jul 2024 |
| Windmere | North Haledon | 57 | 4 | 4 | — | 5 | 8.8 | — | 3 Mar 2026 |
All 19 facilities in Passaic County
Questions and answers
How many deficiencies has Complete Care At Milford Manor LLC been cited for?
26 health deficiencies across the three most recent survey cycles, 1 at the actual-harm or immediate-jeopardy level. The New Jersey median is 21 per facility.
Has Complete Care At Milford Manor LLC been fined?
Yes. CMS lists fines totalling $4K in the period covered.
How does staffing at Complete Care At Milford Manor LLC compare?
Reported total nurse staffing is 3.0 hours per resident per day against a New Jersey median of 3.6 and a national average of 3.9.
Who operates Complete Care At Milford Manor LLC?
It is part of the Complete Care chain. Ownership type is for-profit, corporation. Organisations in the CMS ownership record include Milford Manor Holdco LLC and Pc Gc Holdco LLC. Individual owners and managers are not listed on this site.
When was Complete Care At Milford Manor LLC last inspected?
The most recent survey or investigation in the CMS record is dated 25 Jun 2025; the most recent standard health survey was 7 Mar 2025.
Where does this data come from?
All figures are from the Centers for Medicare & Medicaid Services Care Compare datasets (provider information, health deficiencies, penalties, ownership and quality measures), processed 1 Aug 2026. Ratings and citations may change; the Care Compare record is authoritative.
Provenance
Source: Centers for Medicare & Medicaid Services, Care Compare nursing home datasets (provider information, health deficiencies, penalties, ownership, MDS quality measures, state and national averages), public domain, processed by CMS on 1 Aug 2026. Facility record: Care Compare. Errors in processing are corrected at the next daily build; see corrections.