COMPLETE CARE AT MILFORD MANOR LLC

69 MAPLE ROAD
WEST MILFORD, NJ, 07480
9736975640
CCN: 315276
2
Overall
2
Health
2
Staffing
4
Quality
ChainCOMPLETE CARE
Special FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
NameRole%
MILFORD MANOR HOLDCO LLC5% OR GREATER DIRECT OWNERSHIP INTEREST100%
PC GC HOLDCO LLC5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
PEACE CAPITAL HOLDINGS LLC (DE)5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
SMS 2021 TRUST5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
STEIN, SHALOMCORPORATE OFFICERNOT APPLICABLE
REYES, GRACEOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
ZACKAI, RAANANOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
AYDIN, EMMANUELOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
Penalties (1)
DateTypeAmount
2025-03-07Fine$4K
Health Deficiencies (26)
2025-06-25 · Health
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
2025-03-07 · Health
E
F949 · Administration Deficiencies
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
E
F946 · Administration Deficiencies
Provide training in compliance and ethics.
E
F945 · Infection Control Deficiencies
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
E
F883 · Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
E
F803 · Nutrition and Dietary Deficiencies
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.
D
F757 · Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
G
F697 · Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
D
F692 · Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
D
F686 · Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
D
F583 · Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
D
F580 · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
2024-01-05 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
2023-02-18 · Health
F
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F759 · Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
D
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
D
F697 · Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F660 · Resident Assessment and Care Planning Deficiencies
Plan the resident's discharge to meet the resident's goals and needs.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
D
F578 · Resident Rights Deficiencies
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.
2021-03-08 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F761 · Pharmacy Service Deficiencies
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.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day
3.45
3.68
RN Hrs/Resident/Day
0.53
0.54
LPN Hrs/Resident/Day
0.77
0.81
CNA Hrs/Resident/Day
2.15
2.33
PT Hrs/Resident/Day
0.05
0.12
Data as of 2026-03-01