Nursing homeActive
Complete Care At Milford Manor LLC
69 Maple Road, West Milford, NJ 074809736975640120 certified beds · 112 residentsFor profit - CorporationMedicare and Medicaid
Surveys on file
5
since 2021
Deficiencies
26
● 0● 25● 1
Penalties · 3 yrs
$3,595
1 fine
Last survey
2025-06-25
Complaint
CMS overall
1 / 5
stars as published by CMS
CMS overall 1/5
Health 2
Staffing 1
Quality 4
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · New Jersey Department of Health · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2025-06-25 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-03-07 | Standard | 0121 | CMS-2567 (Care Compare) | — |
| 2024-01-05 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2023-02-18 | Standard | 080 | CMS-2567 (Care Compare) | — |
| 2021-03-08 | Standard | 030 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · New Jersey Department of Health publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-25Record 315276-20250625-F684
F697Provide safe, appropriate pain management for a resident who requires such services.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2025-03-10Record 315276-20250307-F697
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-10Record 315276-20250307-F580
F583Keep residents' personal and medical records private and confidential.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-10Record 315276-20250307-F583
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-10Record 315276-20250307-F686
F692Provide enough food/fluids to maintain a resident's health.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-10Record 315276-20250307-F692
F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-10Record 315276-20250307-F757
F803Ensure 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.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-03-10Record 315276-20250307-F803
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-10Record 315276-20250307-F842
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-10Record 315276-20250307-F880
F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-03-10Record 315276-20250307-F883
F945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-03-10Record 315276-20250307-F945
F946Provide training in compliance and ethics.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-03-10Record 315276-20250307-F946
F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-03-10Record 315276-20250307-F949
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-26Record 315276-20240105-F880
F578Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-03-31Record 315276-20230218-F578
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-03-31Record 315276-20230218-F656
F660Plan the resident's discharge to meet the resident's goals and needs.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-03-31Record 315276-20230218-F660
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-03-31Record 315276-20230218-F689
F697Provide safe, appropriate pain management for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-03-31Record 315276-20230218-F697
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-03-31Record 315276-20230218-F755
F759Ensure medication error rates are not 5 percent or greater.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-03-31Record 315276-20230218-F759
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-03-31Record 315276-20230218-F812
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-03-19Record 315276-20210308-F761
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-03-19Record 315276-20210308-F812
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-04-06Record 315276-20210308-F880
Penalties & enforcement
| Date | Action | Amount | Source |
|---|---|---|---|
| 2025-03-07 | Civil money penalty | $3,595 | CMS · Penalties |
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.42
Facility
New Jersey
National
New Jersey 0.68 · National 0.69
Total nurse hours per resident day2.97
Facility
New Jersey
National
New Jersey 3.85 · National 3.86
Weekend total nurse hours2.44
Facility
New Jersey
National
New Jersey 3.50 · National 3.42
Total nursing staff turnover54%
Facility
New Jersey
National
New Jersey 40% · National 46%
Registered nurse turnover50%
Facility
New Jersey
National
New Jersey 38% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | New Jersey | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 2.6% | 5.4% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 2.9% | 2.3% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 14.9% | 12.7% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 0.6% | 0.8% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 14.0% | 8.7% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 3.6% | 4.6% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 17.8% | 18.8% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Milford Manor Holdco LLC Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | — | — |
| PC Gc Holdco LLC Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | — | — |
| Sms 2021 Trust Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | — | — |
| Aydin, Emmanuel Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Reyes, Grace Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Zackai, Raanan Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Aydin, Emmanuel Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Milford Manor Holdco LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Milford Manor Propco LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| PC Gc Holdco LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Peace Capital Holdings LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Reyes, Grace Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Ruaya, Rizza Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Sms 2021 Trust Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Stein, Shalom Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Stein, Shalom Individual | TRUSTEE OF THE SNF | NOT APPLICABLE | — | — |
| Stein, Shalom Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Stein, Shalom Individual | INDIRECT OWNERSHIP INTEREST | NOT APPLICABLE | — | — |
Part of a chain
Complete Care — 85 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or New Jersey.
No county cost figures on file for Passaic.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Health Center At Bloomingdale Bloomingdale | 5.2 mi | 2025-08-28 | 0180 |
| Cedar Crest/Mountainview Gardens Pompton Plains | 6.3 mi | 2026-01-29 | 083 |
| Lakeland Nursing & Rehab Haskell | 5.4 mi | 2024-07-29 | 050 |
| Phoenix Center for Rehabilitation and Pediatrics Haskell | 5.8 mi | 2025-11-03 | 0191 |
| Arbor Ridge Rehabilitation And Healthcare Center Wayne | 7.6 mi | 2026-06-05 | 0121 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |