Complete Care at Milford Manor LLC
69 Maple Road, West Milford, NJ 07480 · Passaic County · 120 certified beds · avg 112 residents/day · certified since Jun 1, 1989
Part of chain: COMPLETE CARE (85 facilities, chain avg rating 3.1★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Mar 7, 2025 · F-0697
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 10, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (26)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 25, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Mar 7, 2025 | ▲ G · Actual harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Mar 7, 2025 | E · Potential for harm, repeated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Mar 7, 2025 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Mar 7, 2025 | E · Potential for harm, repeated | The facility did not include required infection control training — with written standards, policies, and procedures — as part of its infection prevention program. |
| Mar 7, 2025 | E · Potential for harm, repeated | The facility did not provide its staff with training in compliance and ethics — teaching employees the laws and ethical standards that govern how residents must be treated. |
| Mar 7, 2025 | E · Potential for harm, repeated | The facility did not provide its staff with required training on behavioral health — caring for residents with conditions like dementia, depression, or other mental health needs. |
| Mar 7, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Mar 7, 2025 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. |
| Mar 7, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Mar 7, 2025 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Mar 7, 2025 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Mar 7, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Mar 7, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 5, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Feb 18, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Feb 18, 2023 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Feb 18, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Feb 18, 2023 | D · Potential for harm, one-off | The facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving. |
| Feb 18, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Feb 18, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Feb 18, 2023 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Feb 18, 2023 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Mar 8, 2021 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Mar 8, 2021 | D · Potential for harm, one-off | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Mar 8, 2021 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (8 → 13).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 3 | 0 | D |
| 2023 | 8 | 0 | F |
| 2024 | 1 | 0 | D |
| 2025 | 14 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $3,595.
| Date | Type | Amount / length |
|---|---|---|
| Mar 7, 2025 | Fine | $3,595 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | New Jersey avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.88 | 3.88 | 3.95 | bottom 2% in New Jersey; bottom 10% in the U.S. |
| Registered Nurse hours | 0.41 | 0.67 | 0.69 | bottom 24% in New Jersey; bottom 24% in the U.S. |
| Weekend total nurse staffing | 2.37 | 3.53 | 3.50 | bottom 1% in New Jersey; bottom 6% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.24 | 0.50 | 0.48 | bottom 18% in New Jersey; bottom 21% in the U.S. |
| Total nursing staff turnover (%) | 53.6 | 39.7 | 45.8 | bottom 15% in New Jersey; bottom 28% in the U.S. |
| RN turnover (%) | 50.0 | 37.7 | 42.9 | bottom 26% in New Jersey; bottom 39% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.97, RN 0.42, weekend 2.44. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 3/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Milford Manor Holdco LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 12/27/2021 |
| PC GC Holdco LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 12/27/2021 |
| SMS 2021 Trust | Organization | 5% or Greater Indirect Ownership Interest | — | 12/27/2021 |
| Stein, Shalom | Individual | Indirect Ownership Interest | NOT APPLICABLE | 12/27/2021 |
| Aydin, Emmanuel | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/27/2021 |
| Aydin, Emmanuel | Individual | ADP of the SNF | NOT APPLICABLE | 12/27/2021 |
| Milford Manor Holdco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/27/2021 |
| Milford Manor Propco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/27/2021 |
| PC GC Holdco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/27/2021 |
| Peace Capital Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/27/2021 |
| Reyes, Grace | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/13/2023 |
| Reyes, Grace | Individual | ADP of the SNF | NOT APPLICABLE | 03/13/2023 |
| Ruaya, Rizza | Individual | ADP of the SNF | NOT APPLICABLE | 04/08/2025 |
| SMS 2021 Trust | Organization | ADP of the SNF | NOT APPLICABLE | 12/27/2021 |
| Stein, Shalom | Individual | Managing Control - Governing Body | NOT APPLICABLE | 12/27/2021 |
| Stein, Shalom | Individual | Corporate Officer | NOT APPLICABLE | 12/27/2021 |
| Stein, Shalom | Individual | Trustee of the SNF | NOT APPLICABLE | 12/27/2021 |
| Zackai, Raanan | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/27/2021 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Who reviews your menus, and can I see this week's menu and join my family member for a meal?"
- "What percentage of your residents and staff are vaccinated against flu and pneumonia, and how do you offer the vaccines?"
- "How are staff trained on infection control, and how often is that training refreshed?"
- "What compliance and ethics training do employees receive, and how often is it repeated?"
- "What training do your staff receive for caring for residents with dementia or mental health conditions?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Health Center at Bloomingdale | 5.2 mi | Bloomingdale, NJ | ★★★★★ | 4/5 | |
| Lakeland Nursing & Rehab | 5.4 mi | Haskell, NJ | ★★★★☆ | 3/5 | |
| Phoenix Center for Rehabilitation and Pediatrics | 5.8 mi | Haskell, NJ | ★★★☆☆ | 3/5 | |
| Cedar Crest/Mountainview Gardens | 6.3 mi | Pompton Plains, NJ | ★★★★☆ | 2/5 | abuse |
| Arbor Ridge Rehabilitation and Healthcare Center | 7.6 mi | Wayne, NJ | ★★☆☆☆ | 1/5 | |
| Complete Care at Wayne Hills Rehab & Resp Center | 7.7 mi | Wayne, NJ | ★☆☆☆☆ | 1/5 | |
| Llanfair House Care & Rehabilitation Center | 8.4 mi | Wayne, NJ | ★★☆☆☆ | 2/5 | |
| Oakland Rehabilitation and Healthcare Center | 8.6 mi | Oakland, NJ | ★★★☆☆ | 2/5 | |
| Careone at Wayne | 9.7 mi | Wayne, NJ | ★★★★★ | 5/5 | |
| Avalon Rehab and Care Center | 9.9 mi | Wayne, NJ | ★★★☆☆ | 4/5 | |
| Fallsview Nursing and Rehabilitation Center | 10.5 mi | Boonton, NJ | ★★★☆☆ | 2/5 | |
| Lincoln Park Renaissance | 11.1 mi | Lincoln Park, NJ | ★★★★☆ | 3/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 315276.