Complete Care At Milford Manor LLC

Name: Complete Care At Milford Manor LLC: CMS nursing home record
Creator: Centers for Medicare & Medicaid Services
License: https://www.usa.gov/government-works

West Milford, Passaic County, New Jersey · CCN 315276 · For-profit (Corporation) · part of Complete Care (85 facilities, chain average 3.1 stars)

CMS rates Complete Care At Milford Manor LLC 1 of 5 overall as of August 2026. 120 certified beds, 112 residents a day on average. 26 citations on record from the current inspection cycles, 1 involving actual harm; 1 fine totalling $3,595.

CMS’s ratings

The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.

Overall	★☆☆☆☆ 1 of 5
Health inspections	★★☆☆☆ 2 of 5
Staffing	★☆☆☆☆ 1 of 5
Quality measures	★★★★☆ 4 of 5
Quality: long-stay / short-stay	4 / 3 of 5

Staffing

Total nurse staffing	2.97106 hours per resident per day
Registered nurses	0.42297 hours per resident per day
Weekend total	2.44202 hours per resident per day
Nursing staff turnover	53.6% (registered nurses 50%)
Administrators who left	1

Citations from health inspections

Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.

Survey	Finding	Severity	Status
2025-06-25 complaint survey	Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684	D No actual harm, with potential for more than minimal harm; isolated	Deficient, Provider has date of correction 2025-07-25
2025-03-07	Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0697	G Actual harm that is not immediate jeopardy; isolated	Deficient, Provider has date of correction 2025-03-10
2025-03-07	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. Nutrition and Dietary Deficiencies · tag F0803	E No actual harm, with potential for more than minimal harm; pattern	Deficient, Provider has date of correction 2025-03-10
2025-03-07	Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · tag F0883	E No actual harm, with potential for more than minimal harm; pattern	Deficient, Provider has date of correction 2025-03-10
2025-03-07	Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Infection Control Deficiencies · tag F0945	E No actual harm, with potential for more than minimal harm; pattern	Deficient, Provider has date of correction 2025-03-10
2025-03-07	Provide training in compliance and ethics. Administration Deficiencies · tag F0946	E No actual harm, with potential for more than minimal harm; pattern	Deficient, Provider has date of correction 2025-03-10
2025-03-07	Provide behavior health training consistent with the requirements and as determined by a facility assessment. Administration Deficiencies · tag F0949	E No actual harm, with potential for more than minimal harm; pattern	Deficient, Provider has date of correction 2025-03-10
2025-03-07	Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580	D No actual harm, with potential for more than minimal harm; isolated	Deficient, Provider has date of correction 2025-03-10
2025-03-07	Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · tag F0583	D No actual harm, with potential for more than minimal harm; isolated	Deficient, Provider has date of correction 2025-03-10
2025-03-07	Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686	D No actual harm, with potential for more than minimal harm; isolated	Deficient, Provider has date of correction 2025-03-10
2025-03-07	Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · tag F0692	D No actual harm, with potential for more than minimal harm; isolated	Deficient, Provider has date of correction 2025-03-10
2025-03-07	Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · tag F0757	D No actual harm, with potential for more than minimal harm; isolated	Deficient, Provider has date of correction 2025-03-10
2025-03-07	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842	D No actual harm, with potential for more than minimal harm; isolated	Deficient, Provider has date of correction 2025-03-10
2025-03-07	Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880	D No actual harm, with potential for more than minimal harm; isolated	Deficient, Provider has date of correction 2025-03-10
2024-01-05 complaint survey	Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880	D No actual harm, with potential for more than minimal harm; isolated	Deficient, Provider has date of correction 2024-01-26
2023-02-18	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812	F No actual harm, with potential for more than minimal harm; widespread	Deficient, Provider has date of correction 2023-03-31
2023-02-18	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. Resident Rights Deficiencies · tag F0578	D No actual harm, with potential for more than minimal harm; isolated	Deficient, Provider has date of correction 2023-03-31
2023-02-18	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656	D No actual harm, with potential for more than minimal harm; isolated	Deficient, Provider has date of correction 2023-03-31
2023-02-18	Plan the resident's discharge to meet the resident's goals and needs. Resident Assessment and Care Planning Deficiencies · tag F0660	D No actual harm, with potential for more than minimal harm; isolated	Deficient, Provider has date of correction 2023-03-31
2023-02-18	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689	D No actual harm, with potential for more than minimal harm; isolated	Deficient, Provider has date of correction 2023-03-31
2023-02-18	Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0697	D No actual harm, with potential for more than minimal harm; isolated	Deficient, Provider has date of correction 2023-03-31
2023-02-18	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755	D No actual harm, with potential for more than minimal harm; isolated	Deficient, Provider has date of correction 2023-03-31
2023-02-18	Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · tag F0759	D No actual harm, with potential for more than minimal harm; isolated	Deficient, Provider has date of correction 2023-03-31
2021-03-08	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. Pharmacy Service Deficiencies · tag F0761	D No actual harm, with potential for more than minimal harm; isolated	Deficient, Provider has date of correction 2021-03-19
2021-03-08	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812	D No actual harm, with potential for more than minimal harm; isolated	Deficient, Provider has date of correction 2021-03-19
2021-03-08	Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880	D No actual harm, with potential for more than minimal harm; isolated	Deficient, Provider has date of correction 2021-04-06

Fines and payment denials

Date	Penalty	Amount
2025-03-07	Fine	$3,595

Who owns and runs it

Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.

Name	Role	Share	Since
Milford Manor Holdco LLC Organization	5% or greater direct ownership interest	100%	2021-12-27
PC Gc Holdco LLC Organization	5% or greater indirect ownership interest	—	2021-12-27
Sms 2021 Trust Organization	5% or greater indirect ownership interest	—	2021-12-27
Milford Manor Holdco LLC Organization	adp of the snf	—	2021-12-27
Milford Manor Propco LLC Organization	adp of the snf	—	2021-12-27
PC Gc Holdco LLC Organization	adp of the snf	—	2021-12-27
Peace Capital Holdings LLC Organization	adp of the snf	—	2021-12-27
Sms 2021 Trust Organization	adp of the snf	—	2021-12-27
Aydin, Emmanuel Individual	adp of the snf	—	2021-12-27
Reyes, Grace Individual	adp of the snf	—	2023-03-13
Ruaya, Rizza Individual	adp of the snf	—	2025-04-08
Stein, Shalom Individual	corporate officer	—	2021-12-27
Stein, Shalom Individual	indirect ownership interest	—	2021-12-27
Stein, Shalom Individual	managing control - governing body	—	2021-12-27
Aydin, Emmanuel Individual	operational/managerial control	—	2021-12-27
Reyes, Grace Individual	operational/managerial control	—	2023-03-13
Zackai, Raanan Individual	operational/managerial control	—	2021-12-27
Stein, Shalom Individual	trustee of the snf	—	2021-12-27

What changed

Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.

Tell me when this record changes

One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Complete Care At Milford Manor LLC.

Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Passaic County.