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COMPLETE CARE AT MILFORD MANOR LLC

69 MAPLE ROAD
WEST MILFORD, NJ 07480 · 9736975640 · Passaic County

CMS Star Ratings

Overall★★★★★
Health inspection★★★★★
Staffing★★★★★
Quality measures★★★★★

Facility Facts

Certified beds120
OwnershipFor profit - Corporation
State rank#338

By the numbers

26
Health citations (3 cycles)
0
Immediate-jeopardy (J/K/L)
1
Actual-harm (G/H/I)
$3,595
Federal fines (CMPs)
The trend: Citations are rising — 13 in the most recent cycle versus 4 two cycles ago.

Recent Health Citations

Jun 25, 2025 · Health survey · F-tag 0684
D — No actual harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Mar 7, 2025 · Health survey · F-tag 0880
D — No actual harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Mar 7, 2025 · Health survey · F-tag 0842
D — No actual harm
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.
Mar 7, 2025 · Health survey · F-tag 0757
D — No actual harm
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Mar 7, 2025 · Health survey · F-tag 0692
D — No actual harm
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Mar 7, 2025 · Health survey · F-tag 0686
D — No actual harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Mar 7, 2025 · Health survey · F-tag 0583
D — No actual harm
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Mar 7, 2025 · Health survey · F-tag 0580
D — No actual harm
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.
Mar 7, 2025 · Health survey · F-tag 0949
E — No actual harm
Administration Deficiencies
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Mar 7, 2025 · Health survey · F-tag 0946
E — No actual harm
Administration Deficiencies
Provide training in compliance and ethics.
Mar 7, 2025 · Health survey · F-tag 0945
E — No actual harm
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.
Mar 7, 2025 · Health survey · F-tag 0883
E — No actual harm
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Mar 7, 2025 · Health survey · F-tag 0803
E — No actual harm
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.
Mar 7, 2025 · Health survey · F-tag 0697
G — Actual harm
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Details
Correction status: Corrected Mar 10, 2025 — Deficient, Provider has date of correction
Inspection cycle: 1
Survey origin: Standard survey
Jan 5, 2024 · Health survey · F-tag 0880
D — No actual harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Feb 18, 2023 · Health survey · F-tag 0759
D — No actual harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Feb 18, 2023 · Health survey · F-tag 0755
D — No actual harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Feb 18, 2023 · Health survey · F-tag 0697
D — No actual harm
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Feb 18, 2023 · Health survey · F-tag 0689
D — No actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Feb 18, 2023 · Health survey · F-tag 0660
D — No actual harm
Resident Assessment and Care Planning Deficiencies
Plan the resident's discharge to meet the resident's goals and needs.

Showing the 20 most recent citations. View the full inspection record on CMS Care Compare →

More facilities in New Jersey →

How to read this page. Star ratings and citation counts come from the Centers for Medicare & Medicaid Services (CMS) Care Compare August 2026 dataset, covering the three most recent inspection cycles. Scope/severity letters: D–F no actual harm, G–I actual harm, J–L immediate jeopardy to resident health or safety.

Source: CMS Care Compare, August 2026 dataset. Updated quarterly. Figures come from public CMS records; contact info@theskilledreport.com for corrections.