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Complete Care At Milford Manor LLC

69 Maple Road, West Milford, NJ 07480 · For profit - Corporation · 120 certified beds · (973) 697-5640 Medicare & Medicaid certified

Call the home — (973) 697-5640 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation$3,595 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $3,595 in federal fines (most recent 2025-03-07)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
179 Cahill Cross Rd Ste 314 · (973) 728-1880 · Call to confirm hours
Pharmacy
Grocery
25 Kinnelon Rd · (973) 838-8210 · Call to confirm hours
Park
CYO Field1.2 mi
54 Nosenzo Pond Rd · Typically dawn to dusk
Place of worship
1355 Macopin Rd · (973) 697-7125

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased14.0%8.7%15.4%typical
Long-stay residents who lose too much weight3.6%4.6%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.6%0.9%better
Long-stay residents with a urinary tract infection0.6%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms22.3%12.1%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.9%2.3%3.3%better
Long-stay residents whose ability to walk worsened7.0%8.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication17.8%18.8%18.9%typical
Long-stay residents given the seasonal flu vaccine92.9%97.2%95.3%typical
Long-stay residents with pressure ulcers2.6%5.4%4.7%better
Long-stay residents with worsening bladder/bowel control20.3%15.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table14.9%12.7%17.1%better
Short-stay residents who newly got an antipsychotic medication1.8%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine38.2%80.1%79.4%worse
Short-stay residents rehospitalized after admission22.4%24.9%22.6%typical
Short-stay residents with an outpatient ER visit9.9%8.1%12.0%better
Long-stay hospitalizations per 1,000 resident days2.652.071.67worse
Long-stay outpatient ER visits per 1,000 resident days1.651.111.80typical

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

54.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 138 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

54.1%U.S. median 51.5%
Got home and stayed home
10.1%U.S. median 10.7%
Went back to hospital
71.7%U.S. median 56.6%
Met the expected recovery
0.32U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 71.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 106 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.32 therapist hours per resident per day in 2026Q1 — more than 53% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 19% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF54.1%CMS range 46.8–61.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.1%CMS range 7.7–13.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge71.7%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge72.6%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge64.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.5%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting94.8%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay2.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened7.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.5%CMS range 4.1–11.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.361.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.42
RN hours/ resident / day
0.73
LPN hours/ resident / day
1.82
Aide hours/ resident / day
2.97
Total nurse hours/ resident / day
0.24
RN hoursweekends
53.6%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 111.7 residents a day — about 93% occupied, or roughly 8 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.97 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.42 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.82 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.44 hrs/resident/day on weekends vs 3.19 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.50 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

13
deficiencies at the latest standard inspection (2025-03-07)
8
at the previous standard inspection (2023-02-18)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.

  • Actual harm · Gcited before2025-03-07 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to ensure methadone (an opioid pain medication) was ordered in a timely manner to provide a resident with chronic pain their methadone for three days (03/01/25 through 03/03/25) which caused the resident to miss six doses of the pain medication that resulted in the resident experiencing withdrawal symptoms including; mental pain and physical pain all over their body. This deficient practice was identified for 1 of 38 residents reviewed for pain (Resident #1), and was evidenced by the following: On 03/03/25 at 11:19 AM, Resident #1 was observed awake in bed and stated they did not feel well enough to talk, but wanted to talk later. On 03/03/25 at 1:26 PM, Resident #1 was observed awake in bed and stated that they wanted to talk tomorrow, but they were still not feeling well enough to talk at that time because they were recuperating from the weekend. On 03/04/25 at 11:43 AM, Resident #1 was observed in their room sitting in a chair, dressed in a night gown. Resident #1 stated they were…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-25 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Complaint #: NJ187267 Based on observation, interviews, review of medical records, and review of other pertinent facility documents on 6/24/2025, it was determined that the facility failed to ensure that a resident received the treatment and care in accordance with professional standards of practice by failing to follow a Physician's order for a Stat (immediate ) x-ray. This deficient practice was identified for 1 of 5 residents reviewed (Resident #2), as evidenced by the following: A review of the medical record according to the admission sheet, Resident #2 was admitted with diagnoses that included but were not limited to: Type 2 Diabetes Mellitus Without Complications. According to the Minimum Data Set (MDS), an assessment tool dated 4/14/25 (Comprehensive), Resident #2 had a Brief Interview for Mental Status (BIMS) score of 3/15 indicating severe cognitive impairment and needed supervision or touching assistance with eating. A review of Resident #2's Order Summary Report (OSR) with a print date of 6/23/25, received from the Licensed Nursing Home administrator (LNHA), revealed a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-07 · tag F0803 — failed to meet residents' dietary needs — pattern
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to plan menus for two of 46 residents (Resident (R #1 and R #80) reviewed for menus and for puree and mechanical soft diets. This deficient practice could cause residents to choke on food and/or lose weight. Findings include: A facility policy for menus was requested and not provided. Review of the facility policy titled Food: Quality and palatability, dated 02/02/03, provided by the facility revealed 1. The Dining Services Director and Cook(s) are responsible for food preparation. Menu items are prepared according to the menu, production guidelines, and standardized recipes. Review of the facility's 2024-25 Fall/Winter North Week 1 menu extensions for the week of 03/02/25 through 03/08/25 provided by the facility, revealed diets were planned only regular, NAS [no added salt], CCD [carbohydrate-controlled diet], Renal, and Veg [vegetarian] diet. Review of the facility's diet roster, dated 03/06/25, revealed 35 residents were prescribed a mechanical soft diet and 11 residents were prescribed a pureed diet. 1.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-07 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure residents had accurate vaccine records and were current with their pneumococcal vaccines for five of five residents (Resident #1, #7, #39, #45, and #91 reviewed for pneumonia vaccinations out of a total sample of 38 residents. This practice had the potential to increase the risk for these residents to contract pneumonia. Findings include: Review of the facility's policy titled, Pneumococcal vaccine (Series), dated 09/01/24 and reviewed 05/09/24 revealed, . It is our policy to offer residents and staff immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations. 1. Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine received . The type of pneumococcal vaccine (PCV15, PCV20,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-07 · tag F0945 — failed to train staff on abuse prevention — pattern
    Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, personnel files review, and document review, the facility failed to ensure four of five Certified Nurse Aides (CNA #7, #18, #19, and #14) whose personnel files were reviewed received training on the facility's infection control program, including standards, policies, and procedures of the program. This had the potential to affect all 107 residents in the facility related to Infection Control. Findings include: 1. Review of CNA18's personnel files revealed CNA 18 had a date of hire (DOH) 05/23/22. Review of CNA18's personnel file revealed she had not received Infection Control training since her hire date at the facility. 2. Review of CNA19's personnel files revealed CNA 19 had a DOH of 11/27/23. Review of CNA 19's personnel file revealed she had not received Infection Control training since his hire date at the facility. 3. Review of CNA14's personnel files revealed CNA 14 had a DOH of 05/23/22. Review of CNA14's personnel file revealed she had not received Infection Control training since her hire date at the facility. 4. Review of CNA7's personnel files…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-07 · tag F0946 — pattern
    Provide training in compliance and ethics.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, personnel files review, and document review, the facility failed to ensure five of five Certified Nurse Aides (CNA #7, #18, #19, #12, and #14) received education related to the facility's Compliance and Ethics program. This had the potential to affect 107 residents who resided at the facility. Findings include: Review of the undated, Certified Nursing Assistant Job Description, revealed . Compliance as a condition of employment and performance appraisal. Agreement to abide by all standards, policies and procedures of the facility, including the facility's compliance and ethics program, is a condition of employment . 1. Review of CNA 18's personnel files revealed CNA 18 had a date of hire (DOH) 05/23/22. Review of CNA18's personnel file revealed she had not received Compliance and Ethics training since her hire date at the facility. 2. Review of CNA19's personnel files revealed CNA 19 had a DOH of 11/27/23. Review of CNA 19's personnel file revealed she had not received Compliance and Ethics training since his hire date at the facility. 3. Review of CNA12's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-07 · tag F0949 — failed to train staff on dementia and abuse — pattern
    Provide behavior health training consistent with the requirements and as determined by a facility assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, personnel files review, and document review, the facility failed to ensure five of five Certified Nurse Aides (CNA #7, #18, #19, #12, and #14) received mandatory Behavior Health training. This had the potential to impact all 107 residents in the facility. Findings include: 1. Review of CNA18's personnel files revealed CNA 18 had a date of hire (DOH) 05/23/22. Review of CNA18's personnel file revealed she had not received Behavior Health training since her hire date at the facility. 2. Review of CNA19's personnel files revealed CNA 19 had a DOH of 11/27/23. Review of CNA 19's personnel file revealed she had not received Behavior Health training since his hire date at the facility. 3. Review of CNA12's personnel files revealed CNA 12 had a DOH of 05/23/22. Review of CNA12's personnel file revealed she had not received Behavior Health training since her hire date at the facility. 4. Review of CNA14's personnel files revealed CNA 14 had a DOH of 05/23/22. Review of CNA14's personnel file revealed she had not received Behavior Health training since her hire date at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-07 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to: 1.) notify the physician of a hypoglycemic event that required medication intervention for one of one resident (Resident (R) 40) reviewed for diabetic management out of a total sample of 38. This placed R40 at risk of harm related to hypoglycemia; and 2.) notify the Responsible Party (RP) of an alteration in treatment for one of one (Resident (R) 76) reviewed for notification out of a total sample of 38. R76 was started on a prophylactic regime of Tamiflu without the RP's notification. This prevented the RP from having input into R76's treatment. Findings include: 1. Review of R40's admission Record, located under the Profile tab of the electronic medical record (EMR), indicated R40 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus. Review of R40's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab and with an Assessment Reference Date (ARD) of 02/18/25, revealed the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-07 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and policy review, the facility failed to protect a resident's right to privacy during care for one of 38 sampled residents (Resident (R) 8). This failure had the potential to have a negative impact on the residents' psychosocial well-being. Findings: Review of the facility's Statement of Residents Rights, located in the admission packet, revealed, Right to Privacy: Each resident shall have the right to personal privacy and confidentiality of his or her personal care and clinical records . The facility's foremost concern is to achieve and to maintain the optimum level of independence and dignity of our residents while, at the same time, providing a safe and secure environment . During an observation on 03/05/25 at 5:23 AM, Certified Nursing Aide (CNA)4 was performing personal care for R8. The door of the resident's room was ajar, and the resident's privacy curtain was not drawn. R8 was visible from the hallway and was fully undressed. Review of 8's quarterly Minimum Data Set…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure pressure relieving interventions were consistently implemented and weekly skin assessments were completed for one (Resident (R)37) of two residents reviewed for pressure ulcers out of a total sample of 38 residents. This failure increased the risk of existing pressure ulcers worsening and/or the development of new pressure ulcers. Findings include: Review of the facility policy titled Pressure Ulcer Management, dated 01/24, revealed c. Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record . c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: i. Redistribute pressure (such as repositioning,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-07 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, the facility failed to implement interventions to prevent weight loss for two of five residents (Resident (R) 85 and R80) reviewed for nutrition out of a total sample of 38. This had the potential to cause harm to R85 and R80 related to unaddressed weight loss. Findings include: Review of a policy provided by the facility titled Weight Policy, dated December 2024, indicated Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable god weight range . If nutritional goals are not achieved, care planned interventions will be reevaluated for effectiveness and modified as appropriate. 1. Review of R80's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/16/25 and located in the Electronic Medical Record (EMR) under the MDS tab, revealed an admission date of 11/10/24 and a Brief…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · D2025-03-07 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to monitor for side effects of an anticoagulant (blood thinner) for one of five residents (Resident #98) reviewed for unnecessary drugs out of a total sample of 38. The deficient practice could potentially result in unnoticed bleeding. Findings include: Review of the facility policy titled High Risk Medications- Anticoagulants, dated 09/01/24, revealed, . The resident's plan of care shall alert staff to monitor for adverse consequences. Risks associated with anticoagulants include: a. Bleeding and hemorrhage (bleeding gums, nosebleed, unusual bruising, blood in urine or stool) b. Fall in hematocrit or blood pressure c. Thromboembolism . Review of R98's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/20/25 and located in the electronic medical record (EMR) under the MDS tab, revealed as admission date of 01/13/25 and a Brief Interview for Mental Status (BIMS) score of five out of 15, which indicated R98's cognition was severely impaired. The MDS assessment indicated R98 had…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-07 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain an accurate and complete medical record for one (Resident (R) 40) of 38 sampled residents. R40 suffered a hypoglycemia incident requiring medication intervention. The clinical record contained no documentation of the event. Findings include: Review of the facility's policy titled, Nursing Care of the Resident with Diabetes Mellitus, dated October 2019, indicated . The management of individuals with diabetes mellitus should follow relevant protocols and guidelines . The nurse will closely monitor the diabetes management . Review of R40's admission Record, located under the Profile tab of the electronic medical record (EMR), indicated R40 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus. Review of R40's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab and with an Assessment Reference Date (ARD) of 02/18/25, revealed the resident had a Brief Interview for Mental Status (BIMS) score of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-07 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and facility policy review, the facility failed to: 1. Ensure staff appropriately donned and doffed gloves and perform hand hygiene during care for three of three residents (Resident (R) 3, R62, and R37) out of a total sample of 38 residents and 2. Ensure five of five staff observed (Certified Nurse Aide) (CNA #1), and CNA #5, (Licensed Practical Nurse) (LPN #1) and (Registered Nurse) (RN #1) and RN #4 wore face masks as indicated. This had the potential to affect all 107 residents who resided at the facility. Findings include: Review of the policy titled Transmission-Based Precautions, dated 09/01/24 revealed: 11. Droplet Precautions- . a. Intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions (i.e., respiratory droplets that are generated by a resident who is coughing, sneezing, or talking) . e. Healthcare personnel will wear a facemask for close contact with an infectious resident .…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-05 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #s: NJ00154300, NJ00164616, NJ00164923, NJ00166227, NJ00167635, and NJ00169867. Based on observations, policy review, and interviews, the facility failed to ensure that staff changed gloves when going from a dirty area to a clean area during incontinent care for two of two residents (Resident (R)9 and R4) observed out of a total sample of 11 residents. Failure to appropriately change gloves increases the risk of infection. Findings include: Review of facility policy, title Standard Precautions, revised 03/23, revealed, Standard precautions will be used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents .Standard precautions include the following practices .2. Gloves .e. Change gloves, as necessary, during the care of a resident to prevent cross-contamination from one body…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-02-18 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, review of the Food and Drug Administration website (www.fda.gov) food guide, and facility policy review, the facility failed to ensure proper cleaning of the food thermometer between taking temperatures of different food items. This had the potential to create foodborne illness for 107 of 109 residents who consume food from the kitchen. Findings include: Observation on 02/16/23 at 11:50 AM of [NAME] (CK) and the Dietary Manager (DM) taking temperatures of food for the lunch meal revealed the CK took the temperature of the salisbury steak and wiped off the thermometer probe with a clean white towel and then took the temperature of the roasted chicken. Interview on 02/16/23 at 11:57 AM, the CK stated he was not educated on the cleaning the thermometer probe after each food item. Interview on 02/16/23 at 12:06 PM, the DM stated he did not educate staff on wiping the probe after taking the temperature of each food item. The DM further revealed the thermometer probe should be cleaned with an alcohol wipe between checking the temperatures of food items.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-18 · tag F0578 — failed to honor advance directives / code status — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy review, the facility failed to ensure the electronic medical record (EMR) reflected the resident's code status and failed to completed a Physician's Orders for Life Sustaining Treatment (POLST) form for one (Resident (R)31) of 28 residents reviewed for code status. Findings include: Review of R303's EMR under the Clinical dashboard tab revealed R303 was admitted to the facility on [DATE]. R303's code status was not on the dashboard or on the Face Sheet. Review of R303's POLST located in the EMR under the Misc tab revealed the POLST was not completed, signed, or dated. Review of R303's Care Plan located in the EMR under the Care Plan tab dated 02/11/23 revealed there was no advanced directive or code status listed. Interview on 02/15/23 at 11:30 AM with the Director of Nursing (DON) stated that anyone who does not have an advanced directive or code status is a FULL CODE. She confirmed R303 did not have code status on her Face Sheet, physician's Orders or…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-18 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to develop comprehensive plan of care that included a plan of care for pain for one (Resident (R)305) of two residents reveiwed for a plan of care for pain. Findings include: Review of R305's Face Sheet located in the electronic medical record (EMR) revealed an admission date of 01/23/23. Review of R305's comprehensive Care Plan located in the EMR under the Care Plan tab dated 01/24/23 revealed no evidence of a plan of care for pain. Review of R305's current physician Orders located in the EMR under the Orders tab revealed an order for Tramadol (narcotic pain medication) 50 milligrams (mg) give one tablet at bedtime for pain, and an order for Tramadol, 25 mg, give one tablet every six hours, as needed (PRN) for moderate to severe pain. Interview on 02/14/23 at 1:07 PM with R305's representative (RR) revealed her Dad was always in pain. Interview on 02/17/23 at 12:11 PM with the Minimum Data Set Assistant (MDSA) stated the Care Plans are completed as a group effort and she is unsure why the resident was not care planned for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-18 · tag F0660 — isolated
    Plan the resident's discharge to meet the resident's goals and needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview, and facility policy review, the facility failed to ensure two of three sampled residents (Resident (R)153 and R305) reviewed for discharge planning had a plan of care related to discharge to the community. Findings include: 1. Review R153's Face Sheet located in the electronic medical record (EMR) revealed an admission date of 01/30/23. Review of R153's initial Care Plan located in the EMR under the Care Plan tab revealed no plan of care related to the resident's discharge to the community. Interview with R153 on 02/14/23 at 11:00 AM revealed she was concerned about moving back home and had not heard anything from the facility. She further stated on 02/16/23 at 1:20 PM that she was due to go home and needed a new boot. She revealed she had not heard anything from the facility about discharge plans. Review of the EMR under the Progress Notes tab for R153 revealed no note related to discharge until 02/16/23 at which time a discharge meeting was held to address the resident's discharge. Interview with Licensed Practical Nurse (LPN)5 on 02/16/23 at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure one resident (Resident (R)306) of one reviewed for elopement with a history of wandering and risk for elopement was provided supervision and a monitoring system in place to potentially prevent an elopement. Findings include: Review of R306's electronic medical record (EMR) under the Diagnosis tab revealed the resident was admitted to the facility on [DATE] with diagnoses of dementia and psychotic disorder with delusions. Review of R306's Nursing Comprehensive Assessment located in the EMR under the Assessment tab dated 01/23/23, revealed Resident made attempts to elope from current or previous living situations, resident has conditions which contribute to elopement risk and 6. Wanders - NOT seeking exit. Review of R306's Care Plan located under the Care Plan tab in the EMR dated 01/23/23 revealed the resident had decreased safety awareness, and was at risk for elopement related to: wandering, assess for risk of elopement per policy on 01/29/23,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-18 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interview, and facility policy review, the facility failed to ensure one of 28 sampled residents (Resident (R) 69) reviewed for pain received appropriate pain assessments, pain medication, and pain evaluations. This had the potential for an increase in the resident's risk for pain. Findings include: Review of R69's admission Record located in the Profile tab of the electronic medical record (EMR), revealed R69 was admitted to the facility on [DATE]. R69's diagnoses included seizures, history lumbar vertebrae fracture and spinal stenosis. Review of R69 's Physician's Orders under the Orders tab located in the EMR dated 04/14/22 revealed an order for Asper creme Lidocaine Patch 4 % (Lidocaine) Apply to right shoulder topically in the morning for pain and Tramadol (opioid pain medication) 50 milligrams (mg) give two tablets every six hours as needed (PRN) for pain. Review of R69's comprehensive Care Plan under the Care Plan tab dated 07/14/22 located in the EMR revealed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-18 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview, observation, and review of facility policy, the facility failed to ensure medications were available for administering as ordered to meet the needs of one (Resident (R)83) of 11 residents observed during medication pass observation. Findings include: Review of R83's Physician's Orders under the Orders tab located in the EMR dated 06/27/22 revealed an order for Apixaban (blood thinner) 5 milligrams (mg) one tablet by mouth twice a day. During medication pass observation on 02/15/23 at 8:30 AM LPN5 was unable to fine R83's Apixaban medication. LPN5 said the medication was not available and she would call the pharmacy. LPN5 said the medication was ordered and they did not receive enough medication. LPN5 said, the medication is important since it is a blood thinner. During an interview on 02/16/23 at 12:03 PM the Director of Nursing (DON) said We ordered the Eliquis [Apixaban] on 01/26/23 and they only sent 14 and they should have sent 30. The medication was supposed to come in the overnight delivery on 01/15/23, but it did not. During a phone…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-18 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of facility policy, the facility failed to ensure the medication error rate was less than 5 percent (%). Observation of medication administration revealed out of 26 opportunities two errors were observed resulting in a medication error rate of 7.69%. Specifically, medications were not available for two residents (Resident (R) 69 and (R) 83) out of 11 residents observed during medication pass. Findings include: 1. Review of R69's Physician's Orders under the Orders tab located in the electronic medical record (EMR) dated 04/14/22 revealed an order for Asper creme Lidocaine Patch 4 % (Lidocaine) Apply to right shoulder daily for pain. During medication pass observation and interview on 02/15/23 at 5:42 AM, Licensed Practical Nurse (LPN)2 said R69's Asper creme Lidocaine Patch 4 % (Lidocaine patch) was not available and they were waiting for a shipment. 2.Review of R83's current Physician's Orders under the Orders tab located in the EMR revealed an order for Apixaban (blood thinner) five milligrams (mg) one tablet by mouth…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-03-08 · tag F0761 — failed to label and store drugs safely — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and review of facility documentation, it was determined that the facility failed to a.) date eye drops bottle when opened and discard unused eye drops and b.) failed to utilize the medication refrigerator solely to store appropriate medications. The deficient practice was observed in 1 of 5 medication carts inspected and 1 of 2 medication refrigerators inspected and evidenced by the following: On 3/02/21 11:45 AM, the surveyor inspected the medication cart on the short hall of Unit two in the presence of the Licensed Practical Nurse Unit Manager (LPNUM) who was also the medication nurse. The surveyor observed three bottles of Timolol Maleate 0.5% eye drops used to treat Glaucoma for Resident #7. The first bottle had an open date of 12/29/20 and had approximately one drop in the bottle. The second bottle was opened and not dated, but had a delivery date from the Pharmacy Provider of 1/22/21. The bottle was nearly full. The third bottle was not opened and had a delivery date from the Pharmacy Provider of 2/24/21. The LPNUM stated the medication was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-03-08 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review and policy review, it was determined that the facility failed to a.) failed to sanitize and air dry steam table pans in a manner to prevent microbial growth and b.) failed to maintain the kitchen environment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: The surveyor reviewed the facility's policy titled, Dietary Pot Washing Procedure and Emergency Manual Dishwashing Procedure dated 1/2021. The policy indicated that items are to be air dried on drying rack. On 3/2/2021 at 10:00 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following: 1. The surveyor observed five of five red sprinkler caps above the cook top area soiled with a brown grease-like substance and white particles. 2. On a shelf in the dishwashing area of the kitchen, the surveyor observed four half sheet pans stacked with water between them, four one quarter sheet pans stacked with water between them, six 4…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-03-08 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of facility documentation, it was determined that two nurses, a Licensed Practical Nurse (LPN) and Registered Nurse (RN), observed during a medication pass observation failed to perform hand hygiene in a manner to reduce the transmission of infection. The deficient practice was evidenced by the following: On 3/4/2021 at 8:15 AM, the surveyor observed the LPN perform handwashing prior to administering oral medications to a resident. The LPN wet her hands, applied soap, lathered outside of running water for 8 seconds, rinsed under running water, dried her hands with a paper towel, and closed the faucet with a dry paper towel. When questioned by the surveyor, the LPN stated she should sing the Happy Birthday song twice while lathering outside of running water. On 3/4/2021 at 8:30 AM, the surveyor observed the RN perform handwashing prior to administering oral medications to a resident. The RN wet her hands, applied soap, lathered for 7 seconds, rinsed under running water, dried her hands with a paper towel, and closed the faucet with a dry…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$3,595 in federal fines across 1 penalty.

  • $3,595 — penalty dated 2025-03-07

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to COMPLETE CARE — 85 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 53.1-2.1 vs chain
Health inspection 2 of 52.7-0.7 vs chain
Staffing 1 of 52.3-1.3 vs chain
Quality measures 4 of 54.4-0.4 vs chain
The other 84 homes this chain runs (chain average 3.1★, per CMS)
1 of 5Complete Care At Chestnut Hill LLCPassaic, NJ 1 of 5Complete Care At HagerstownHagerstown, MD 1 of 5Complete Care At Harston Hall LLCFlourtown, PA 1 of 5Complete Care At Kimberly Hall NorthWindsor, CT 1 of 5Complete Care At Laplata LLCLaplata, MD 1 of 5Complete Care At Wayne Hills Rehab & Resp CenterWayne, NJ 1 of 5Complete Care at Care AgeBrookfield, WI 1 of 5Complete Care at KensingtonWaukesha, WI 1 of 5Complete Care at Maple Grove LLCMadison, WI 1 of 5Complete Care at Margate ParkChicago, IL 1 of 5Complete Care at the BoulevardChicago, IL 2 of 5Complete Care At Brakeley ParkPhillipsburg, NJ 2 of 5Complete Care At Fox HillVernon, CT 2 of 5Complete Care At Harborage LLCNorth Bergen, NJ 2 of 5Complete Care At Harrington CourtColchester, CT 2 of 5Complete Care At HyattsvilleHyattsville, MD 2 of 5Complete Care At Inglemoor, LLCEnglewood, NJ 2 of 5Complete Care At Monmouth, LLCLong Branch, NJ 2 of 5Complete Care At Ocean Grove LLCOcean Grove, NJ 2 of 5Complete Care At Prospect Heights LLCHackensack, NJ 2 of 5Complete Care At Regent LLCHackensack, NJ 2 of 5Complete Care at Christian Home LLCWaupun, WI 2 of 5Complete Care at Grande PrairiePleasant Prairie, WI 2 of 5Complete Care at Heritage LLCDundalk, MD 2 of 5Complete Care at Linwood, LLCLinwood, NJ 2 of 5Complete Care at Nazareth LLCStoughton, WI 2 of 5Complete Care at Voorhees, LLCVoorhees, NJ 2 of 5Complete Care at Wall LLCWall, NJ 3 of 5Complete Care At Fair Lawn EdgePaterson, NJ 3 of 5Complete Care At Holiday CityToms River, NJ 3 of 5Complete Care At Lehigh LLCMacungie, PA 3 of 5Complete Care At Oak Ridge LLCCharleston, WV 3 of 5Complete Care At Orange ParkEast Orange, NJ 3 of 5Complete Care At Phillipsburg, LLCPhillipsburg, NJ 3 of 5Complete Care At Severna Park LLCSeverna Park, MD 3 of 5Complete Care At Shrewsbury LLCShrewsbury, NJ 3 of 5Complete Care At Silver Lake LLCDover, DE 3 of 5Complete Care At SpringbrookSilver Spring, MD 3 of 5Complete Care at Brick LLCBrick, NJ 3 of 5Complete Care at Corsica Hills LLCCentreville, MD

Showing 40 of 84; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
MILFORD MANOR HOLDCO LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 12/27/2021
PC GC HOLDCO LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 12/27/2021
SMS 2021 TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 12/27/2021
STEIN, SHALOMIndividualINDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; TRUSTEE OF THE SNFsince 12/27/2021
AYDIN, EMMANUELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/27/2021
REYES, GRACEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/13/2023
ZACKAI, RAANANIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/27/2021
MILFORD MANOR PROPCO LLCOrganizationADP OF THE SNFsince 12/27/2021
PEACE CAPITAL HOLDINGS LLCOrganizationADP OF THE SNFsince 12/27/2021
RUAYA, RIZZAIndividualADP OF THE SNFsince 04/08/2025

CMS files one row per role, so the 18 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$14.1M
Net patient revenuemost recent cost report
+7.0%
Operating marginrevenue minus expenses
$1.6M
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 72%Medicare 14%Other / private 15%

About 72% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$342per resident / day
operating cost
$10,408per month
≈ monthly operating cost
$368per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NJ

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Jersey Medicaid page.

Typical monthly cost in New Jersey
$12,775/mo
Nursing home (semi-private)
$14,448/mo
Nursing home (private)
$8,710/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 315276. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-07, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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