Inspection Reports for Stratford Manor Rehabilitation And Care Center
787 Northfield Ave, West Orange, NJ, 07052
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
8.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
58% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
92% occupied
Based on a April 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Notice
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
This document serves to inform covered components and individuals about the privacy practices related to medical information, including how information may be used, disclosed, and the rights of individuals under these practices.
Findings
The notice explains the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of the department to protect privacy.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Routine
Deficiencies: 6
Date: Sep 22, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to staff credential verification, resident transfer and discharge procedures, bed hold policies, resident assessments, physician visits, medication storage, and medical record maintenance.
Findings
The facility was found deficient in verifying licensed staff credentials upon hire, providing complete bed hold policy notifications including reserve payment information, documenting resident transfers and discharges properly, completing timely resident assessments, ensuring attending physician visits were documented monthly as required, properly storing medications, and maintaining complete and organized medical records.
Deficiencies (6)
Failed to ensure licensed staff credentials were verified upon hire for 3 of 7 licensed staff reviewed.
Failed to provide required documentation or notification related to resident's needs, appeal rights, or bed-hold policies for 2 residents.
Failed to complete admission Minimum Data Set (MDS) within required timeframe for 1 resident.
Failed to ensure attending physician visited and documented monthly visits, with proper alternation with Advanced Nurse Practitioner, for 1 resident.
Failed to properly store medication; 19 unidentified loose tablets/capsules found in medication cart.
Failed to maintain complete, accurately documented, readily accessible, and systematically organized medical records for 2 residents.
Report Facts
Licensed staff with unverified credentials: 3
Unidentified tablets/capsules: 19
Residents reviewed: 28
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Human Resources Manager | Interviewed regarding license verification process | |
| Director of Operations | Interviewed regarding license verification process | |
| Licensed Nursing Home Administrator | Notified of license verification and transfer documentation concerns | |
| Director of Nursing | Present during notification of deficiencies | |
| Regional Nurse | Present during notification of deficiencies | |
| Chief Nursing Officer | Present during notification of deficiencies | |
| Director of Social Services | Interviewed regarding bed hold policy and transfer notifications | |
| Licensed Practical Nurse/Unit Manager | Interviewed regarding transfer and discharge practices | |
| Registered Nurse/MDS Coordinator | Interviewed regarding MDS assessments and transfer documentation | |
| Unit Manager | Interviewed regarding physician consultation follow-up | |
| Licensed Practical Nurse | Observed medication storage and disposal of loose meds | |
| Advanced Practice Nurse | Interviewed regarding physician visit alternation and resident care | |
| Unit Manager | Interviewed regarding physician documentation and medical record maintenance |
Inspection Report
Complaint Investigation
Census: 122
Capacity: 132
Deficiencies: 9
Date: Apr 24, 2024
Visit Reason
A Recertification Survey was conducted from 4/15 to 4/24/2024 to determine compliance with 42 CFR Part 483 for Long-Term Care Facilities. Complaint investigations were also completed during this survey based on complaint numbers NJ155673, 156615, 156876, 158687, 161314, and 164633.
Complaint Details
Complaint investigations were conducted for complaint numbers NJ155673, 156615, 156876, 158687, 161314, and 164633. The survey included review of staffing ratios, resident care, medication administration, and infection control. Deficiencies were substantiated as evidenced by observations, interviews, and record reviews.
Findings
Multiple deficiencies were cited including failure to ensure reasonable accommodations for resident needs, failure to complete and submit resident assessments timely, failure to develop and implement person-centered comprehensive care plans, failure to follow physician orders, failure to provide respiratory care properly, failure to provide pharmaceutical services according to standards, failure to maintain food safety, and failure to maintain infection control practices. Corrective actions were documented for each deficiency.
Deficiencies (9)
Failure to ensure the resident's call light was readily accessible for reasonable accommodations.
Failure to complete and submit electronically the Minimum Data Set (MDS) assessments within required timeframes.
Failure to develop and implement a person-centered comprehensive care plan to meet residents' medical needs.
Failure to maintain professional standards of nursing practice by not following physician orders for residents.
Failure to provide respiratory/tracheostomy care and suctioning according to professional standards.
Failure to provide pharmaceutical services in accordance with professional standards including medication administration and documentation.
Failure to maintain food procurement, storage, preparation, and sanitation to prevent foodborne illness.
Failure to maintain infection prevention and control practices including environmental cleaning and hand hygiene.
Failure to maintain minimum staffing ratios as required by New Jersey regulations.
Report Facts
Census: 122
Total Capacity: 132
Sample Size: 27
Deficiency Completion Dates: 5
Deficiency Completion Date: 5
Inspection Report
Routine
Deficiencies: 12
Date: Apr 15, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, medication management, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including accessibility of resident call lights, timely submission of Minimum Data Set (MDS) assessments, development of comprehensive care plans, adherence to physician orders, medication administration practices, respiratory care, physician order signatures, pharmaceutical services, medication storage, infection control, and food safety.
Deficiencies (12)
Failed to ensure resident's call light was readily accessible for 1 resident.
Failed to complete and submit electronically the Minimum Data Set (MDS) within required timeframes for 4 residents.
Failed to develop and implement a complete care plan meeting all resident needs for 2 residents.
Failed to maintain professional nursing standards by not following physician orders for 2 residents.
Failed to provide safe and appropriate respiratory care including oxygen administration and storage for 1 resident.
Failed to ensure residents' primary physicians signed and dated monthly physician orders for 6 residents.
Failed to provide pharmaceutical services ensuring manufacturer's medication administration specifications were followed for 1 resident.
Failed to ensure licensed pharmacist performed monthly drug regimen review and reported irregularities for 3 residents.
Failed to ensure resident did not receive unnecessary medication by failing to document effectiveness or indication for off-label use for 1 resident.
Failed to ensure medications were stored and labeled appropriately including controlled substances lock and medication expiration dates.
Failed to establish appropriate infection control practices for environmental cleaning in resident room.
Failed to store potentially hazardous foods properly and maintain kitchen environment and equipment in a sanitary manner.
Report Facts
Residents reviewed: 24
Residents affected: 1
Residents affected: 4
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 6
Residents affected: 1
Residents affected: 3
Residents affected: 1
Medication doses remaining: 55
Medication doses total: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant CNA#1 | Named in relation to splint application for Resident #5. | |
| Licensed Practical Nurse LPN#1 | Named in relation to splint application and oxygen care findings. | |
| Licensed Practical Nurse LPN/Unit Manager | Named in relation to splint application and care plan responsibilities. | |
| Rehab Director RD | Named in relation to splint application and therapy program. | |
| Registered Nurse RN | Named in relation to oxygen therapy and resident care. | |
| Infection Preventionist Nurse RN IPN/RN | Named in relation to infection control education and oxygen tubing storage. | |
| Licensed Practical Nurse LPN#2 | Named in relation to oxygen therapy documentation. | |
| Licensed Practical Nurse LPN#3 | Named in relation to oxygen therapy documentation. | |
| Licensed Nursing Home Administrator LNHA | Named in relation to multiple findings and management discussions. | |
| Director of Nursing DON | Named in relation to multiple findings and management discussions. | |
| Consultant Pharmacist CP#1 | Named in relation to medication regimen review. | |
| Consultant Pharmacist CP#2 | Named in relation to medication regimen review and survey interviews. | |
| Owner of Consultant Pharmacist Company OCP | Named in relation to medication administration instructions. | |
| Licensed Practical Nurse LPN | Named in relation to medication administration for Resident #25. | |
| Licensed Practical Nurse LPN/UM | Named in relation to medication regimen review and care plan responsibilities. | |
| Licensed Practical Nurse LPN/UM | Named in relation to medication cart inspection. | |
| Dietary Director DD | Named in relation to food storage and kitchen sanitation. |
Inspection Report
Routine
Census: 113
Deficiencies: 0
Date: May 5, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations and recommended COVID-19 practices.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Routine
Census: 123
Deficiencies: 6
Date: Mar 8, 2022
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. The survey was a Standard Survey conducted from 2/23/22 through 3/8/22.
Findings
The facility was found to have multiple deficiencies including failure to administer medications as ordered, failure to complete full body assessments after falls, improper respiratory care and tracheostomy suctioning, medication administration errors, and life safety code violations related to fire alarm systems and sprinkler coverage. An Immediate Jeopardy situation was identified but removed after implementation of a Removal Plan. Corrective actions and plans of correction were submitted and accepted.
Deficiencies (6)
Failure to administer medications in accordance with physician's orders and appropriately reconcile discharge medications.
Failure to ensure a Registered Nurse completed full body assessments after a fall for 1 of 4 residents reviewed for falls.
Failure to administer respiratory care and tracheostomy suctioning according to physician's orders and professional standards for 5 of 7 residents reviewed.
Failure to ensure medications were administered properly, including medication errors and missing doses for multiple residents.
Failure to provide notification by audible and visible signals for 1 of 1 outside enclosed courtyard in accordance with NFPA 101.
Failure to maintain fire extinguisher inspections and documentation for 1 of 14 portable fire extinguishers.
Report Facts
Census: 123
Sample size: 28
Deficiencies cited: 6
Date of Compliance: Apr 14, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | DON | Named in relation to findings on fall assessments and medication administration |
| Licensed Practical Nurse #1 | LPN | Named in relation to fall incident reports and medication administration |
| Licensed Nursing Home Administrator | LNHA | Named in relation to acknowledgement of findings and policies |
| Assistant Director of Nursing | ADON | Named in relation to acknowledgement of findings and policies |
| Registered Nurse #1 | RN | Named in relation to fall assessments and medication administration |
| Licensed Practical Nurse #3 | LPN | Named in relation to medication administration and inventory discrepancies |
| Consultant Pharmacist | CP | Named in relation to medication administration and audit findings |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Mar 8, 2022
Visit Reason
The inspection was conducted as part of an annual survey of Stratford Manor Rehabilitation and Care Center to assess compliance with professional standards of quality, medication management, respiratory care, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to ensure Registered Nurses completed full body assessments after falls, improper respiratory care and equipment storage, medication administration errors including missed doses and inaccurate controlled substance accounting, and failure to ensure anti-seizure medications were administered as ordered or properly reconciled. An Immediate Jeopardy was identified related to omitted anti-seizure medications and lack of monitoring for rebound seizures.
Deficiencies (5)
Failure to ensure a Registered Nurse completed full body assessments after a fall prior to moving the resident.
Failure to provide safe and appropriate respiratory care and ensure respiratory equipment was stored and dated properly.
Failure to ensure medications were administered in accordance with professional standards and controlled anti-seizure medication was accurately accounted for.
Failure to ensure a licensed pharmacist performed monthly drug regimen review including identification of medication administration irregularities.
Failure to ensure residents were free from significant medication errors, including omitted anti-seizure medications and lack of monitoring for rebound seizures, resulting in Immediate Jeopardy.
Report Facts
Residents affected: 1
Residents affected: 5
Residents affected: 2
Residents affected: 1
Residents affected: 2
Medication volume: 175
Medication volume: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in medication error finding and fall assessment interview |
| LPN #1 | Licensed Practical Nurse | Named in medication error finding and fall incident reports |
| DON | Director of Nursing | Interviewed regarding fall assessments, medication errors, and facility policies |
| LNHA | Licensed Nursing Home Administrator | Acknowledged medication errors and facility deficiencies |
| ADON | Assistant Director of Nursing | Interviewed regarding medication and respiratory care deficiencies |
| CP | Consultant Pharmacist | Interviewed regarding medication irregularities and anti-seizure medication administration |
| PPR | Provider Pharmacy Representative | Interviewed regarding medication delivery and timelines |
Inspection Report
Plan of Correction
Census: 120
Deficiencies: 2
Date: Jan 21, 2022
Visit Reason
The inspection was conducted to assess compliance with New Jersey Administrative Code, Chapter 8:39, Standards for Licensure of Long Term Care Facilities, specifically focusing on staffing ratios as mandated by state law.
Findings
The facility failed to maintain the required minimum direct care staff-to-resident ratios for the day shift and did not ensure that no fewer than half of all staff members were Certified Nursing Assistants (CNAs) on the overnight shifts, as required by New Jersey state regulations.
Deficiencies (2)
Failure to maintain the required minimum direct care staff-to-resident ratios for the day shift.
Failure to provide that no fewer than half of all staff members shall be Certified Nursing Assistants (CNA) on the overnight shifts.
Report Facts
Residents on day shift: 120
CNAs required on day shift: 15
CNAs present on day shift: 11
CNAs present on day shift: 12
CNAs present on day shift: 13
CNAs present on day shift: 14
CNAs present on day shift: 11
CNAs present on day shift: 12
CNAs present on day shift: 13
Total staff required on overnight shift: 9
Total staff present on overnight shift: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding staffing challenges and corrective actions | |
| Staffing Coordinator | Interviewed regarding staffing ratios and scheduling practices |
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 0
Date: Aug 4, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ144253, NJ144724, and NJ144193.
Complaint Details
Complaint numbers NJ144253, NJ144724, and NJ144193 were investigated and found to be unsubstantiated as the facility was in compliance.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Report Facts
Sample Size: 11
Inspection Report
Routine
Census: 118
Deficiencies: 0
Date: May 12, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 1
Date: Dec 30, 2020
Visit Reason
The inspection was conducted based on complaints NJ00135218, NJ00135548, and NJ00136596 to determine compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Complaint Details
The complaint investigation was based on complaint intake NJ00135548. The facility was found not in compliance with quality of care requirements related to wound treatment documentation and completion.
Findings
The facility failed to ensure wound treatments were completed per physician's orders for one resident (Resident #2) out of three investigated for wound care. Missing documentation of wound treatment completion was noted on multiple dates, despite staff assertions that treatments were performed.
Deficiencies (1)
Failure to ensure wound treatments were completed per physician's orders for Resident #2.
Report Facts
Census: 108
Sample size: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses (DON) | Interviewed regarding wound care documentation and staff education. | |
| Wound Care Nurse (WCN) | Interviewed regarding wound treatment completion and documentation. |
Inspection Report
Routine
Census: 108
Deficiencies: 0
Date: Dec 10, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations and recommended COVID-19 practices.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Routine
Census: 107
Deficiencies: 0
Date: Nov 27, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample size: 4
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