Inspection Reports for
Complete Care At Milford Manor Llc
69 Maple Road, West Milford, NJ, 07480
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
10.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
96% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
86% occupied
Based on a July 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Notice
Deficiencies: 0
Date: Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice explains the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 24, 2025
Visit Reason
The inspection was conducted based on a complaint (NJ187267) regarding the facility's failure to ensure a resident received treatment and care according to a physician's order for a STAT chest x-ray following a choking incident.
Complaint Details
Complaint NJ187267 was substantiated. The facility failed to ensure timely follow-up and execution of a STAT chest x-ray order after Resident #2 experienced distress and choking. The delay was confirmed through interviews with nursing staff, the Director of Nursing, the Licensed Nursing Home Administrator, and the resident's physician.
Findings
The facility failed to follow a physician's order for a STAT chest x-ray for Resident #2 after a choking incident, resulting in delayed diagnostic imaging. Interviews and record reviews confirmed that the x-ray was not performed promptly and follow-up procedures were not adequately executed.
Deficiencies (1)
Failure to provide appropriate treatment and care according to physician's order for a STAT chest x-ray after a choking incident.
Report Facts
Residents reviewed: 5
Residents affected: 1
BIMS score: 3
Date of physician order: Jun 10, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator (LNHA) | Interviewed regarding follow-up on x-ray order and incident | |
| Director of Nursing (DON) | Interviewed regarding expectations for nurse follow-up on STAT x-ray orders | |
| LPN #2 | Assigned nurse on 6/10/25 shift who reported x-ray was not done during shift | |
| LPN #3 | Entered STAT chest x-ray order and reported incident to doctor | |
| Resident #2's doctor | Provided expectations for STAT order completion and notification of delays |
Inspection Report
Routine
Deficiencies: 13
Date: Mar 7, 2025
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, medication management, infection control, and facility policies.
Findings
The facility was found deficient in multiple areas including failure to notify physicians and responsible parties about significant clinical events, failure to protect resident privacy, inadequate pressure ulcer care, failure to prevent weight loss, failure to provide timely pain medication, failure to monitor anticoagulant side effects, inadequate menu planning for special diets, incomplete medical records, lapses in infection control practices including improper glove use and mask wearing, inaccurate pneumococcal vaccination records, and lack of required staff training in infection control, compliance and ethics, and behavior health.
Deficiencies (13)
Failed to notify physician of hypoglycemic event and failed to notify responsible party of medication change.
Failed to protect resident privacy during care.
Failed to ensure pressure ulcer care and weekly skin assessments were consistently implemented.
Failed to implement interventions to prevent weight loss and failed to document meal intake.
Failed to provide timely methadone pain medication causing withdrawal symptoms.
Failed to monitor for side effects of anticoagulant medication and failed to care plan anticoagulant use.
Failed to plan menus for pureed and mechanical soft diets.
Failed to maintain accurate and complete medical records for hypoglycemia event.
Failed to ensure proper infection control practices including glove use, hand hygiene, and mask wearing during outbreak.
Failed to ensure residents had accurate and current pneumococcal vaccination records.
Failed to provide infection control training to certified nurse aides.
Failed to provide compliance and ethics training to certified nurse aides.
Failed to provide behavior health training to certified nurse aides.
Report Facts
Deficiencies cited: 13
Weight loss percentage: 14.52
Weight loss percentage: 8.87
Missed medication doses: 6
Residents on mechanical soft diet: 35
Residents on pureed diet: 11
Certified Nurse Aides without infection control training: 4
Certified Nurse Aides without compliance and ethics training: 5
Certified Nurse Aides without behavior health training: 5
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 1
Date: Jul 31, 2024
Visit Reason
The inspection was conducted based on complaints NJ00171980, NJ00172632, and NJ00170194 to investigate compliance with federal and state regulations regarding staffing ratios and care standards.
Complaint Details
Complaint investigation based on complaints NJ00171980, NJ00172632, and NJ00170194. The facility was found substantially compliant with federal requirements but deficient in state staffing requirements.
Findings
The facility was found to be in substantial compliance with federal requirements but was not in compliance with New Jersey state staffing regulations, specifically failing to meet minimum staff-to-resident ratios on 14 of 28 day shifts. The facility submitted a plan of correction to address staffing deficiencies.
Deficiencies (1)
Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratio as mandated by the State of New Jersey for 14 of 28 day shifts.
Report Facts
Census: 103
Day shifts deficient in CNA staffing: 14
Sample Size: 5
Staffing ratios required: 8
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 2
Date: Jan 5, 2024
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health due to multiple complaint numbers listed, to investigate compliance with long term care facility regulations.
Complaint Details
The complaint investigation involved multiple complaint numbers and found the facility not in substantial compliance with 42 CFR Part 483, Subpart B, based on observed infection control deficiencies and staffing shortages.
Findings
The facility was found not in substantial compliance with infection prevention and control requirements, specifically failing to ensure staff changed gloves appropriately during resident care, increasing infection risk. Additionally, the facility failed to maintain required minimum staffing ratios for certified nurse aides (CNAs) on multiple shifts over several months.
Deficiencies (2)
Failure to ensure staff changed gloves when moving from dirty to clean areas during care for residents, increasing risk of infection.
Failure to maintain required minimum staff-to-resident ratios as mandated by New Jersey law on multiple day, evening, and night shifts.
Report Facts
Survey Census: 105
Sample Size: 11
Staffing Deficiencies: 43
Staffing Deficiencies: 1
Staffing Deficiencies: 4
Deficiency Counts: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Infection Preventionist Nurse | Conducted in-service and competency evaluations related to infection control deficiencies. | |
| Certified Nursing Assistant (CNA) 1 | Observed failing to change gloves appropriately during resident care. | |
| Director of Nursing (DON) | Interviewed and confirmed glove changing policy. | |
| Assistant Director of Nursing (ADON) | Interviewed and confirmed glove changing policy. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 5, 2024
Visit Reason
The inspection was conducted based on multiple complaints regarding infection prevention and control practices at the facility.
Complaint Details
Complaint numbers NJ00154300, NJ00164616, NJ00164923, NJ00166227, NJ00167635, and NJ00169867 were investigated. The complaint was substantiated based on observations and policy review.
Findings
The facility failed to ensure that staff changed gloves when moving from dirty to clean areas during incontinent care for two residents, increasing the risk of infection. Observations, policy review, and interviews confirmed non-compliance with infection control standards.
Deficiencies (1)
Failure to ensure staff changed gloves when going from a dirty area to a clean area during incontinent care for two residents.
Report Facts
Residents observed: 11
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) 1 | Observed not changing gloves appropriately during incontinent care | |
| Director of Nursing (DON) | Interviewed and confirmed gloves should be changed when moving from dirty to clean areas | |
| Assistant Director of Nursing (ADON) | Interviewed and confirmed gloves should be changed when moving from dirty to clean areas |
Inspection Report
Abbreviated Survey
Census: 115
Deficiencies: 0
Date: Oct 18, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 7
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Oct 18, 2023
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Complete Care at Milford Manor LLC.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Census: 109
Capacity: 109
Deficiencies: 17
Date: Feb 18, 2023
Visit Reason
A Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health to assess compliance with federal and state regulations.
Findings
The facility was found not to be in substantial compliance with multiple regulatory requirements including advance directives documentation, comprehensive care planning, discharge planning, accident prevention, pain management, medication availability and administration, food safety, staffing ratios, and life safety code violations related to emergency lighting, fire alarm system testing, sprinkler system installation and maintenance, smoke barrier integrity, corridor door functionality, fire drills, and portable space heater use.
Deficiencies (17)
Failed to ensure electronic medical record reflected resident's code status and completion of POLST form.
Failed to develop and implement a comprehensive care plan including plan of care for pain for one resident.
Failed to develop and implement an effective discharge planning process for two residents.
Failed to ensure adequate supervision and monitoring system to prevent elopement for one resident.
Failed to provide appropriate pain assessments, medication, and evaluations for one resident.
Failed to ensure medication was available for administration as ordered for one resident.
Medication error rate exceeded 5% due to unavailable medications for two residents during medication pass observation.
Failed to properly clean food thermometer between taking temperatures of different food items.
Failed to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey.
Failed to provide emergency lighting for the generator transfer switch.
Failed to complete smoke detection sensitivity test for all photo electric smoke detectors in the past two years.
Failed to ensure two sunrooms were protected with automatic sprinkler systems.
Failed to inspect and test the 10,000 gallon exterior sprinkler water tank in accordance with NFPA 25.
Failed to ensure two corridor doors were capable of resisting the passage of smoke and one door lacked functional latching hardware.
Failed to ensure penetrations in smoke barriers were protected and smoke barriers were continuous from floor to ceiling.
Failed to ensure fire drills included transmission of fire alarm signal and simulation of emergency fire conditions.
Failed to ensure space heaters used in offices did not exceed temperatures of 212 degrees Fahrenheit.
Report Facts
Survey Census: 109
Sample Size: 28
Medication error rate: 7.69
Staffing Deficiencies: 13
Staffing Deficiencies: 8
Fire drills reviewed: 12
Smoke detectors: 99
Sprinkler water tank capacity: 10000
Sunroom dimensions: 33
Sunroom dimensions: 15
Sunroom dimensions: 27
Sunroom dimensions: 9
Corridor door damage: 1.25
Corridor door damage: 12
Smoke barrier gap: 6
Smoke barrier gap: 8
Smoke barrier gap: 6
Smoke barrier gap: 24
Smoke barrier gap: 36
Unsealed smoke barrier openings: 3
Fire drills missing alarm transmission: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in multiple findings related to fire safety, emergency lighting, sprinkler system, smoke barriers, and space heater observations | |
| Director of Nursing | Named in findings related to medication availability, pain management, and space heater policy | |
| Licensed Practical Nurse 2 | LPN | Named in medication administration and pain management findings |
| Licensed Practical Nurse 5 | LPN | Named in medication administration findings |
Inspection Report
Routine
Deficiencies: 8
Date: Feb 18, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey of Complete Care at Milford Manor LLC to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to document residents' code status and advance directives, incomplete care plans for pain and discharge, inadequate supervision to prevent elopement, failure to provide appropriate pain management, medication availability issues leading to medication errors, and improper food thermometer cleaning practices.
Deficiencies (8)
Failed to ensure the electronic medical record reflected the resident's code status and failed to complete a Physician's Orders for Life Sustaining Treatment (POLST) form for one resident.
Failed to develop a comprehensive plan of care for pain for one resident.
Failed to ensure two residents had a plan of care related to discharge to the community.
Failed to provide supervision and monitoring system to prevent elopement for one resident with a history of wandering.
Failed to ensure one resident received appropriate pain assessments, medication, and evaluations.
Failed to ensure medications were available for administering as ordered to meet the needs of one resident.
Failed to ensure medication error rate was less than 5 percent; observed 7.69% error rate due to unavailable medications for two residents.
Failed to ensure proper cleaning of the food thermometer between taking temperatures of different food items.
Report Facts
Residents reviewed for code status: 28
Residents reviewed for plan of care for pain: 2
Residents reviewed for discharge planning: 3
Medication administration opportunities observed: 26
Medication error rate: 7.69
Residents affected by thermometer cleaning deficiency: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | LPN | Confirmed verification of resident's code status upon admission |
| Licensed Practical Nurse 2 | LPN | Observed medication pass and noted missing Lidocaine patch |
| Licensed Practical Nurse 5 | LPN | Observed medication pass and unable to find Apixaban medication |
| Licensed Practical Nurse 6 | LPN | Confirmed missing Lidocaine patch and pain complaints from resident |
| Director of Nursing | DON | Confirmed missing code status documentation, medication issues, and pain assessment deficiencies |
| Social Services Director | SSD | Confirmed lack of discussion about advanced directives and discharge planning |
| Minimum Data Set Assistant | MDSA | Reported care plans are group efforts and unsure why pain and discharge plans were missing |
| Administrator | Administrator | Discussed expectations for discharge planning and elopement system decisions |
| Regional Director of Clinical Services | RDCS | Discussed expectations for discharge planning |
| Pharmacist | Pharmacist | Confirmed medications should be available as ordered |
| Dietary Manager | DM | Confirmed lack of education on cleaning thermometer probe between food items |
| Cook | CK | Observed wiping thermometer probe with towel instead of proper cleaning |
Inspection Report
Routine
Census: 110
Deficiencies: 0
Date: Jul 7, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Inspection Report
Routine
Census: 109
Deficiencies: 0
Date: Aug 19, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Routine
Census: 94
Deficiencies: 3
Date: Mar 8, 2021
Visit Reason
Routine standard survey conducted on 3/8/21 to assess compliance with 42 CFR Part 483, Subpart B for long term care facilities.
Findings
The facility was found not in substantial compliance due to deficiencies in medication labeling and storage, food safety and sanitation practices, and infection prevention and control, including improper hand hygiene by nursing staff.
Deficiencies (3)
Failure to date eye drop bottles when opened and improper storage of medications in the medication refrigerator.
Failure to sanitize and air dry steam table pans properly and maintain a sanitary kitchen environment.
Failure to establish and maintain an infection prevention and control program including improper hand hygiene by nursing staff.
Report Facts
Sample Size: 21
Deficiency Correction Completion Date: Mar 19, 2021
Deficiency Correction Completion Date: Apr 6, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Unit Manager (LPNUM) | Present during medication cart and refrigerator inspection; involved in medication labeling deficiency. | |
| Food Service Director (FSD) | Present during kitchen inspection; involved in food safety deficiency. | |
| Administrator | Interviewed regarding medication labeling and food safety concerns. | |
| Director of Nursing | Provided in-service training and corrective action plans related to medication labeling, hand hygiene, and infection control. | |
| MDS Coordinator | Interviewed regarding hand hygiene policy and competencies. |
Inspection Report
Routine
Deficiencies: 3
Date: Mar 8, 2021
Visit Reason
The inspection was conducted to assess compliance with medication labeling and storage, food safety and sanitation, and infection prevention and control practices at the nursing home.
Findings
The facility was found deficient in properly dating opened eye drop bottles and storing medications appropriately, maintaining sanitary kitchen conditions including proper drying of dishware, and ensuring nurses performed hand hygiene correctly during medication administration.
Deficiencies (3)
Failure to date eye drop bottles when opened and discard unused eye drops; medication refrigerator used to store inappropriate items such as food.
Failure to sanitize and air dry steam table pans properly and maintain kitchen environment sanitary to prevent contamination and food borne illness.
Two nurses failed to perform hand hygiene in a manner to reduce transmission of infection during medication pass observation.
Report Facts
Medication carts inspected: 5
Medication refrigerators inspected: 2
Red sprinkler caps observed: 5
Sheet pans observed stacked with water: 16
Hand hygiene competencies completed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Unit Manager (LPNUM) | Present during medication cart and refrigerator inspection; medication nurse | |
| Food Service Director (FSD) | Present during kitchen inspection and observed unsanitary conditions | |
| Licensed Practical Nurse (LPN) | Observed failing to perform proper hand hygiene during medication administration | |
| Registered Nurse (RN) | Observed failing to perform proper hand hygiene during medication administration | |
| Administrator | Interviewed regarding deficiencies and policies | |
| Director of Nursing | Interviewed regarding deficiencies and policies | |
| MDS Coordinator | Interviewed regarding hand hygiene policy and competencies |
Inspection Report
Abbreviated Survey
Census: 96
Deficiencies: 2
Date: Feb 3, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found not in compliance with 42 CFR §483.80 infection control regulations, specifically failing to ensure adequate screening of staff and visitors and appropriate infection control practices during rapid COVID-19 testing, including improper use of personal protective equipment and lack of disinfection procedures.
Deficiencies (2)
Failure to adequately and thoroughly screen staff and visitors/vendors prior to entrance to the facility.
Failure to follow appropriate infection control practices during rapid COVID-19 testing, including not wearing gowns or gloves, not disinfecting the testing table, and lack of a facility policy and procedure for rapid COVID-19 testing.
Report Facts
Census: 96
Sample size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Conducted rapid COVID-19 testing observed not following proper infection control protocols. | |
| Administrator | Acknowledged deficiencies in screening questionnaire and could not explain improper PPE use during testing. | |
| Director of Nursing | Director of Nursing | Provided counseling and re-in-service to LPN on proper rapid test protocol. |
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