Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stratford Manor Rehabilitation And Care Center during CMS and state inspections, most recent first.
Deficiencies were observed in the storage and cleanliness of food preparation areas and equipment. Specifically, soiled oven knobs and handles were noted in the food preparation area, and dented cans were found in the dry storage room still in rotation for use. The Dietary Director acknowledged the need for these areas to be cleaned and for dented cans to be removed from use.
The facility failed to ensure that primary physicians signed and dated monthly physician orders for six residents over several months, as required by facility policy. Staff interviews confirmed that physicians were expected to sign orders monthly in the EHR, but this was not consistently done.
The facility failed to follow the manufacturer's specifications for administering Alendronate Sodium (Fosamax) to a resident, resulting in the medication being given with other drugs, contrary to the required instructions. The DON acknowledged that the administration times should have been adjusted to comply with the cautionary warnings.
The facility failed to ensure that the Consultant Pharmacist identified and reported medication irregularities for three residents, including improper documentation of vital signs, lack of physician documentation for continued medication use, and improper administration of medications.
A resident with Alzheimer's and urinary retention was given tamsulosin without proper documentation of its effectiveness, indication, or benefit vs. risk statement. The medication, started during a hospital readmission, was not documented in the EMR or care plan until noted by a surveyor.
The facility failed to ensure that a resident's call light was readily accessible. The resident, with cerebrovascular disease and left-side hemiparesis, was observed twice unable to reach the call light cord, which was under their right chest. The RN confirmed the call light should be on top of the blanket and repositioned it. The facility's policy did not address the need for the call light cord to be within reach.
The facility failed to submit MDS assessments electronically within the required 14-day period for four residents. The MDS Coordinator/Registered Nurse acknowledged the late submissions, stating she was only responsible for one of the late submissions. The survey team informed the facility management of these findings.
The facility failed to develop and implement comprehensive care plans for two residents. One resident, admitted with a myocardial infarction, did not have a care plan for their anticoagulant medication. Another resident, being treated for osteoporosis, did not have a care plan for their condition. Both deficiencies were confirmed by facility staff.
The facility failed to follow physician orders for two residents, resulting in one resident not wearing a prescribed elbow resting splint and another not having bunny booties and heel pads while in bed. Staff confusion and lack of proper documentation in the eMAR and eTAR contributed to these deficiencies.
The facility failed to administer oxygen therapy according to the physician's order, ensure nurses signed the eMAR when oxygen was administered, and properly store respiratory tubing and cannula. A resident was observed with an oxygen concentrator set incorrectly and the nasal cannula improperly stored. Medical records indicated the oxygen was to be administered at 1 LPM PRN, but the eMAR showed no documentation of administration.
The facility failed to ensure proper storage and labeling of medications, including latanoprost eye drops and Fluticasone/salmeterol discus, and did not maintain a locked box for controlled substances. Additionally, the temperature log for the medication room's refrigerator was incomplete.
The facility failed to establish appropriate infection control practices for environmental cleaning for a resident. A surveyor noticed a splash of a creamy substance on the wall near the resident's bedside table. The RN identified it as tube feeding milk and stated housekeeping would clean it. The LNHA later stated the area was already cleaned but provided no further information.
Deficiencies in Food Storage and Cleanliness Identified
Penalty
Summary
The facility was found to have deficiencies related to the storage and cleanliness of food preparation areas and equipment. Specifically, observations revealed soiled oven knobs and handles in the food preparation area, as well as dented cans in the dry storage room that were still in rotation for use. The Dietary Director acknowledged that these areas should have been cleaned and that dented cans should not be in use.
Failure to Ensure Monthly Physician Orders Signed
Penalty
Summary
The facility failed to ensure that the residents' primary physicians signed and dated monthly physician orders, which is necessary to confirm that the residents' current medical regimen was appropriate. This deficiency was observed for six residents over several months. Specifically, the medical records for Residents #12, #16, #22, #111, #13, and #62 showed that their physicians had not signed or electronically signed the monthly physician's orders for various months in 2024. The absence of these signatures was confirmed through a review of the hybrid medical records, which lacked both hand-signed and electronic signatures for the specified months. Interviews with staff, including two Licensed Practical Nurses (LPNs) and the Director of Nursing (DON), revealed that the primary physicians were expected to sign the orders monthly in the Electronic Health Records (EHR). However, this practice was not consistently followed. The administration acknowledged the issue when it was brought to their attention by the survey team. The facility's policy, dated December 2023, mandates that all verbal or written orders must be signed by the prescriber monthly, which was not adhered to in these cases.
Failure to Follow Manufacturer's Specifications for Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring that manufacturer's specifications were followed for the administration time and sequence of Alendronate Sodium (Fosamax) for one resident. The resident, who had an intact cognition and was diagnosed with age-related osteoporosis, received multiple medications together in the early morning, contrary to the specific instructions for Fosamax administration. The instructions required Fosamax to be taken with water at least 30 minutes before any other food, drink, or medication, and the resident's other medications were scheduled too closely to comply with these instructions. The surveyor's review of the resident's medical records and interviews with the care providers revealed that the Fosamax was administered at the same time as other medications, such as Pantoprazole and Ferrous Sulfate, which were scheduled for 6:30 AM and 6:00 AM respectively. The Licensed Practical Nurse (LPN) responsible for administering these medications confirmed that they were given together, and the Director of Nursing (DON) acknowledged that the administration times should have been adjusted to follow the cautionary warnings for Fosamax. Further investigation showed that the cautionary warning was clearly labeled on the Fosamax packaging, and the facility's policy for medication administration emphasized the importance of following manufacturer recommendations and cautionary warnings. Despite this, the facility did not ensure that the medication administration times were adjusted accordingly, leading to the deficiency. The DON admitted that the nurses should have been aware of the specific instructions and that the medication times should have been changed to comply with the manufacturer's specifications.
Failure to Identify and Report Medication Irregularities
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported irregularities to the physician and the facility regarding several medications for three residents. For Resident #72, the CP did not identify the absence of documentation of the resident's systolic blood pressure (SBP) and heart rate (HR) in the electronic medication administration record (eMAR) for the medication Metoprolol, which was ordered to be held if SBP was less than 110 and HR was less than 60. Additionally, the CP did not identify the lack of physician documentation for the continued use of Enoxaparin, a medication for deep vein thrombosis prophylaxis, from August 2023 to April 2024. For Resident #103, the CP failed to report the off-label use of Tamsulosin (Flomax), a medication typically used to treat urinary retention in males, which was prescribed without documented indications or rationale. The resident had an indwelling urinary catheter and was scheduled for discharge, but there was no documentation supporting the use of Tamsulosin in the resident's electronic medical record (EMR) or the CP's reports. For Resident #25, the CP did not identify the improper administration of Alendronate (Fosamax), which should be given as the first medication in the morning with no other medications for at least 30 minutes. The resident's eMAR showed that Fosamax was administered at the same time as other medications, contrary to the specific instructions. Although a recommendation was made by the CP on 2/13/24, it was not acted upon, and subsequent CP reports did not repeat the recommendation. The facility's Director of Nursing (DON) acknowledged the issue but stated that the facility had not received the complete report from the CP company.
Failure to Document Unapproved Use of Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, the facility did not document the effectiveness, appropriate indication, or benefit vs. risk statement for the unapproved use of tamsulosin for one resident. The resident, who had Alzheimer's disease and urinary retention with an indwelling urethral catheter, was unable to answer basic questions due to cognitive impairment. The medication tamsulosin, typically used to treat benign prostatic hyperplasia, was started during a hospital readmission and continued without proper documentation in the resident's electronic medical record (EMR) or care plan. The surveyor's review of the EMR and physician's progress notes from 1/1/24 to 4/18/24 revealed no documentation of urinary retention or the use of tamsulosin until a discharge note was made after the surveyor brought it to the facility's attention. The Director of Nursing (DON) acknowledged the oversight and stated that the medication was started at the hospital, agreeing that the physician should have documented the continued unapproved use of tamsulosin in the resident's chart.
Inaccessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was readily accessible. This deficiency was identified for a resident with cerebrovascular disease and left-side hemiparesis, who had moderate cognitive impairment. On two separate occasions, the surveyor observed the resident in bed and unable to reach the call light cord, which was found under the resident's right chest. The resident attempted to reach the call light three times but was unsuccessful. The RN confirmed that the call light should be on top of the blanket for accessibility and repositioned it accordingly. The facility's policy on call bell audits did not specifically address the need for the call light cord to be within the resident's reach.
Failure to Timely Submit MDS Assessments
Penalty
Summary
The facility failed to complete and submit the Minimum Data Set (MDS) assessments electronically within the required 14-day period as mandated by the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. This deficiency was identified for four residents. Resident #2 had a Quarterly MDS with an Assessment Reference Date (ARD) of 1/15/24, which was due by 1/29/24 but was submitted on 2/9/24. Resident #5 had a Quarterly MDS with an ARD of 12/12/23, due by 12/26/23, but was submitted on 1/10/24. Resident #35 had an Entry MDS with an ARD of 10/2/23, due by 10/16/23, but was submitted on 10/17/23. Resident #225 had an Annual MDS with an ARD of 9/22/22, due by 10/6/22, but was submitted on 10/20/22. Additionally, a Discharged Return Not Anticipated (DRNA) assessment for Resident #225 with an ARD of 10/10/22 was due by 10/24/22 but was submitted on 11/7/22. The MDS Coordinator/Registered Nurse (MDSC/RN) acknowledged the late submissions during an interview, stating that she started working in February 2023 and was only responsible for the late submission of Resident #5's MDS. The MDSC/RN confirmed awareness of the late submissions and stated that she follows the RAI manual. The survey team informed the Licensed Nursing Home Administrator and Director of Nursing of these findings and concerns during a meeting on 4/18/24.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan to meet the medical needs of two residents. Resident #13, who was admitted with a diagnosis of Myocardial Infarction, had a physician's order for Eliquis, an anticoagulant medication. However, the care plan for this medication was not created. This was confirmed by the Licensed Practical Nurse (LPN) assigned to the resident, who acknowledged that a care plan should have been developed for the anticoagulant medication. Resident #25, who had an intact cognition as indicated by a BIMS score of 15 out of 15, was actively being treated for osteoporosis with Alendronate Sodium. Despite this, the resident's Interdisciplinary Plan of Care (IDCP) did not include a care plan for osteoporosis. The Director of Nursing (DON) confirmed that the resident should have had a care plan completed for osteoporosis. The facility's policy requires that comprehensive care plans be developed based on thorough assessments and be updated as the resident's condition changes, but this was not adhered to in these cases.
Failure to Follow Physician Orders for Two Residents
Penalty
Summary
The facility failed to maintain professional standards of nursing practice by not following physician orders for two residents. Resident #5, who has cerebrovascular disease and left-side hemiparesis, was observed without the prescribed left-hand elbow resting splint on multiple occasions. The physician's order for the splint was not included in the electronic Medication Administration Record (eMAR) or electronic Treatment Administration Record (eTAR). Interviews with staff revealed confusion about who was responsible for applying the splint, and it was found that the order was not properly documented in the eTAR, leading to the splint not being applied as required. Resident #35, who has primary osteoarthritis and cellulitis of the left toe, was observed without the prescribed bunny booties and heel pads while in bed. The physician's orders for these items were also not included in the eMAR or eTAR. Staff interviews indicated that the resident did not have the required items in their room, and there was a lack of awareness among the staff about the orders. The resident was found wearing surgical shoes during therapy, which were not ordered, and the bunny booties were later found in the laundry. The facility's policy on specialty devices states that residents requiring preventative measures and positioning devices should be provided with these devices according to physician orders. However, the failure to document and follow these orders resulted in the residents not receiving the necessary care. The surveyor team discussed these findings with the Administrator and Director of Nursing, highlighting the deficiencies in maintaining professional standards of nursing practice.
Failure to Administer and Document Oxygen Therapy Correctly
Penalty
Summary
The facility failed to administer oxygen therapy according to the physician's order, ensure that all nurses signed the electronic Medication Administration Record (eMAR) when oxygen was administered, and properly store respiratory tubing and cannula. This deficiency was identified for one resident who was observed with an oxygen concentrator set at 3 liters per minute (LPM) instead of the prescribed 1 LPM. Additionally, the nasal cannula was improperly stored, wrapped around the half-side rail of the bed, and not placed in a plastic bag as required for infection control. The resident, who was admitted with diagnoses including acute on chronic diastolic heart failure, seizures, hypertension, and atrial fibrillation, was observed on multiple occasions with the oxygen concentrator set incorrectly and the nasal cannula improperly stored. The resident's medical records indicated that the oxygen was to be administered at 1 LPM as needed (PRN) for shortness of breath, but the eMAR showed no documentation that the nurses signed off on the administration of the PRN oxygen. Interviews with the nursing staff revealed a lack of adherence to the facility's policies and procedures for oxygen administration and storage. The Licensed Practical Nurse (LPN) confirmed that the oxygen concentrator was set incorrectly and that the nasal cannula should have been stored in a plastic bag. The Infection Preventionist Nurse also confirmed that the improper storage of the nasal cannula was not in line with the facility's infection control practices. Despite these observations and interviews, the eMAR remained unsigned for the dates when oxygen was administered, indicating a failure in proper documentation and adherence to physician orders.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications were stored and labeled appropriately. This deficiency was identified in one of three medication carts and one of two medication storage rooms inspected. Specifically, a vial of latanoprost eye drops and a package of Fluticasone/salmeterol discus 500/50 were found without dates indicating when they were opened. Additionally, a package of Fluticasone/salmeterol discus 250/50 was found to have been opened for more than 30 days. The medication cart's lockable box for controlled substances was also found to be unlocked due to excess medication packages blocking it from fully closing. The temperature log for the medication room's refrigerator had blank spaces for three specific dates, indicating a failure to document temperatures as required. The surveyor discussed these concerns with the LPN assigned to the medication cart, who acknowledged the issues. The surveyor also reviewed the manufacturer package inserts for latanoprost and Fluticasone/salmeterol, which specify storage requirements that were not met. The Director of Nursing (DON) confirmed the deficiencies and stated that the medications of concern had been removed and staff had been educated. The facility's policy for medication storage was reviewed, which mandates that all controlled drugs be stored under double-lock and key, a requirement that was not adhered to in this instance.
Inadequate Infection Control Practices for Environmental Cleaning
Penalty
Summary
The facility failed to establish appropriate infection control practices for environmental cleaning for one resident. On 04/15/24 at 10:40 AM, during rounds in a resident's room, a surveyor noticed a splash of a creamy substance on the right-side wall near the metal pole, extending from the resident's bedside table to the electrical outlet. The RN identified the substance as tube feeding milk and stated that housekeeping would be asked to clean it. On 04/17/24 at 1:25 PM, the surveyor team discussed the concern with the LNHA and DON, who stated that the area was already cleaned but did not provide further information.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near West Orange
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Livingston Post Acute Care | 0.3 mi | — | 21 | 0 |
| Alaris Health At West Orange | 0.7 mi | — | 1 | 0 |
| Inglemoor Rehabilitation And Care Center | 1.4 mi | — | 0 | 0 |
| Complete Care At Summit Ridge | 1.6 mi | — | 3 | 0 |
| Daughters Of Israel Pleasant Valley Home | 1.8 mi | — | 22 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.