Public Record
Complete Care at Milford Manor Llc
From CMS
Facility profile
- CMS overall rating
- 1 / 5
- Certified beds
- 120
- Avg. residents per day
- 107.5
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 37
- Inspections on file
- 7
- Last inspection
- 2025-06-25
*CMS
*CMS
*CMS
Citations
37 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0757Generalpotential for harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- 0803Generalpotential for harm
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.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0697Seriousactual harm
Provide safe, appropriate pain management for a resident who requires such services.
- 0914Generalpotential for harm
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0355Generalpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0883Generalpotential for harm
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- 0945Generalpotential for harm
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
- 0946Generalpotential for harm
Provide training in compliance and ethics.
- 0949Generalpotential for harm
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
- 0686Generalpotential for harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0692Generalpotential for harm
Provide enough food/fluids to maintain a resident's health.
- 0580Generalpotential for harm
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- 0583Generalpotential for harm
Keep residents' personal and medical records private and confidential.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0781Generalpotential for harm
Have restrictions on the use of portable space heaters.
- 0578Generalpotential for harm
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.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0660Generalpotential for harm
Plan the resident's discharge to meet the resident's goals and needs.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0697Generalpotential for harm
Provide safe, appropriate pain management for a resident who requires such services.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0372Generalpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0291Generalpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0351Generalpotential for harm
Install an approved automatic sprinkler system.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0761Generalpotential for harm
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.
FAQ
Questions and answers
- What is Complete Care at Milford Manor Llc?
- Complete Care at Milford Manor Llc is a Medicare- and Medicaid-certified nursing home in West Milford, NJ, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 315276.
- What is the CMS rating for Complete Care at Milford Manor Llc?
- Complete Care at Milford Manor Llc has a CMS overall rating of 1 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Complete Care at Milford Manor Llc have?
- Complete Care at Milford Manor Llc is certified for 120 beds. It serves an average of 107.5 residents per day.
- How many citations does Complete Care at Milford Manor Llc have?
- Complete Care at Milford Manor Llc has 37 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Complete Care at Milford Manor Llc last inspected?
- Complete Care at Milford Manor Llc was last inspected on June 25, 2025. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
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