Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 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.
The facility failed to provide complete bed hold notices and transfer documentation for multiple residents. For two residents, the emergency transfer forms lacked reserve bed payment details, appeal-rights information, and documentation of who received the notice. For another resident, the chart lacked a physician transfer order, physician awareness of the transfer, and a discharge summary, and the transfer forms were incomplete with blank fields and inconsistent information.
Missing Documentation for License Verification on Hire: The facility failed to document that license verification was completed before hire for 3 of 7 licensed new hires reviewed. Three CNAs had undated NJDOH Public Registry printouts with no evidence the checks were done prior to hire, while another CNA had a dated verification showing compliance. The HRM said licenses were checked for active status before hire, and the DoO stated the printer did not always print the date.
Late Admission MDS Completion: The facility failed to complete a resident’s admission MDS within the required timeframe. The RN/MDSC acknowledged the MDS was due within 14 days of admission and stated it was completed late after the Lead MDS had left and while she had been away from the facility for several weeks. The facility’s MDS policy required the MDS department to schedule, complete, certify, and submit MDS assessments in accordance with CMS regulations.
Physician Visit Documentation Not Completed as Required: The facility failed to ensure that an attending MD completed and documented required face-to-face visits for a resident whose record showed diagnoses including stroke, heart disease, HTN, and hospice care. Surveyors found no MD visit documentation for an extended period, while the ANP documented the resident during that time and stated the MD usually did not see the resident with them. The DON and LNHA could not locate MD notes in the paper chart, and the facility policy required the attending physician to visit at least every 60 days with NP visits alternating.
An inspection found 19 unidentified tabs/caps loose in the bottom drawer of the East med cart. The LPN could not identify the meds or who they were for and stated they should not have been stored that way, and the LPN/UM agreed the meds should not have been in the cart in that condition. The facility’s med storage policy stated meds are to be stored in the containers in which they are received and kept in an orderly manner in cabinets, drawers, or carts.
The facility failed to keep complete and accurately documented resident records for two residents. One resident’s chart lacked documentation showing that neurology and cardiology consult recommendations were relayed to the MD, followed, or declined, and staff reported the CT brain and monitor were not completed or returned as expected. Another resident’s discharge record lacked documentation of a transfer care plan and prior notice to the resident representative about the transfer and reason for transfer, and the issue was not identified in the facility’s recent QAPI review.
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.
Incomplete Bed Hold Notices and Missing Transfer Documentation
Penalty
Summary
The facility failed to provide complete bed hold notifications for residents transferred to the hospital. For one resident with diagnoses including heart failure, prior stroke, hemiplegia/hemiparesis, and COPD, the record showed two emergency transfer bed hold notices for hospital transfers related to lethargy and shortness of breath. Those notices did not include information about the reserve bed payment policy plan, the explanation of the right to appeal the transfer, or information identifying to whom the notice was given. The Director of Social Services stated the form was used for cognitively intact residents or resident representatives, but also acknowledged there was no documentation showing the notice was sent or who received it, and that she was unaware of the regulation requiring reserve payment information. A second resident, who had diagnoses including cerebral infarction, palliative care, diabetes with retinopathy, aphasia, major depressive disorder, and psychosis, was transferred to another facility/hospice setting. The record contained no documented physician order for the transfer, no physician note showing awareness of the transfer before it occurred, and no discharge summary in the medical record. The transfer documentation was incomplete: the eINTERACT transfer form listed a discharge to hospital with a reason for transfer, while the Universal Transfer Form had blank fields for date, destination, code status, reason, attached documents, and sending/receiving contacts. Staff interviews confirmed that the physician order and documentation of the reason for transfer should have been in the record, but they were not present. A third resident, who had diagnoses including acute cholecystitis and other digestive system complications and was cognitively intact, had multiple emergency transfers to the hospital. For each transfer, the chart contained a Notice of Emergency Transfer form, but the forms did not include reserve bed payment information and did not identify whether the resident or resident representative had been informed. Social Services documentation and the bed hold binder also lacked evidence that the resident or representative was notified about reserve payment for bed hold. The DSS stated she was not aware of the notification requirement and had no additional documentation regarding the bed hold transfer notices.
Missing Documentation for License Verification on Hire
Penalty
Summary
The facility failed to ensure licensed staff credentials were verified upon hire for 3 of 7 licensed staff reviewed among 10 newly hired employees. During review of employee files, Staff Member #6, a CNA hired on 6/12/24, had a New Jersey Department of Health online Public Registry license verification printout that was not dated, and there was no documented evidence that the license was verified prior to the date of hire. Staff Member #7, a CNA hired on 10/2/24, also had an undated NJDOH verification printout with no documented evidence that the license was verified prior to hire. Staff Member #8, a CNA hired on 5/1/25, likewise had an undated NJDOH verification printout with no documented evidence that the license was verified prior to the date of hire. A review of Staff Member #9, a CNA hired on 12/31/24, showed a dated NJDOH verification printout dated 12/29/24, which documented that the license was verified upon hire. During interview, the HRM stated that she would make sure a license was active and in good standing on the New Jersey website prior to the hire date, while the DoO stated that the printer did not always print the date on it and confirmed that the verification printouts for Staff Members #6, #7, and #8 did not have dates. The facility's New Hire Policy and Resident Abuse/Neglect Misappropriation of Property Policy both required screening of applicants through contact with State licensing boards and registries, including verification of CNA status through the New Jersey Nurse Aide Registry and contact with the applicable licensing board for licensed professionals.
Late Admission MDS Completion
Penalty
Summary
The facility failed to complete the admission MDS within the required timeframe for Resident #4. According to the CMS RAI User’s Manual, the comprehensive admission assessment must be completed no later than the admission date plus 13 calendar days, but the resident’s comprehensive and modified admission MDS had an ARD of 8/12/25, was completed on 8/21/25, and was transmitted and accepted on 9/7/25, which was more than 14 days beyond the required timeframe. The surveyor reviewed the resident’s eMR on 9/22/25 and identified this as the only resident reviewed for timing of assessments with this deficient practice. During interview, the RN/MDS Coordinator stated that the admission MDS was due within 14 days of admission and acknowledged that the admission MDS for ARD 8/12/25 was completed late and should have been completed on 8/18/25. She also stated that she was responsible for MDS assessments for all residents after the Lead MDS left two months earlier and that she had been away from the facility for three weeks in July 2025. The facility’s MDS policy stated that the MDS department schedules MDS and care plan meetings in accordance with regulations, assures completeness and accuracy of the MDS, coordinates, signs, certifies completion, and submits MDS data to CMS.
Physician Visit Documentation Not Completed as Required
Penalty
Summary
The facility failed to ensure that the resident’s attending physician completed required face-to-face visits and documented monthly visits, with the physician alternating with the advanced nurse practitioner (ANP) every other month. For one resident reviewed, the medical record showed no documented attending physician visit from 5/1/24 through 12/31/24, while the documented visits during that period were completed by the ANP. The resident’s admission record reflected diagnoses including cerebral infarction, atherosclerotic heart disease, and essential hypertension, and the record also showed the resident was receiving hospice care. Surveyor interviews and record review showed that the Unit Manager stated the MD came in only occasionally, usually in the evenings, and that the ANP and hospice nurse visited the resident. The APN stated they were a contracted vendor who visited three days a week, supplemented physician visits, and usually saw the resident alone without the MD, and believed the last MD visit was the prior year. The DON and LNHA were unable to locate MD notes for the period reviewed in the paper chart, and the DON stated the MD documented in the paper chart and only recently in the EMR. The facility’s physician visit policy stated the attending physician must visit at least every 60 days after the initial period, and that an alternate schedule may be established with nurse practitioner visits alternating, not to exceed every 60 days.
Improper Storage of Unidentified Medications in Cart
Penalty
Summary
Medication storage was found to be improper in 1 of 3 medication carts observed on 1 of 2 nursing units. During an inspection of the East Cart, the surveyor observed 19 unidentified tablets and/or capsules loose in the bottom of the 3rd drawer. When asked, the LPN present stated the cart was being cleaned out, could not identify the medications or who they were for, and said they should not have been stored that way because they were not clean. The LPN/UM also stated the medications should not have been in the cart in that condition and believed the cart had been previously cleaned. The surveyor observed the assigned LPN dispose of the unidentified medications in a self-contained drug disposal system. The facility’s Medication Storage Policy stated that medications are to be stored in the containers in which they are received and in an orderly manner in cabinets, drawers, or carts. The report also cited NJAC 8:39-29.4(d)(g) and referenced the New Jersey Nurse Practice Act.
Incomplete and Poorly Documented Resident Records
Penalty
Summary
The facility failed to maintain complete, accurately documented, readily accessible, and systematically organized medical records for two residents. For one resident, the record review showed diagnoses including heart failure, sequelae of stroke, hemiplegia/hemiparesis, and COPD, with a BIMS score of 13 indicating cognitive intactness. The chart contained a neurology consult recommending a CT brain and follow-up in two months, and a cardiology consult recommending a five-day monitor, follow-up in one month, and continuation of medications including metoprolol and apixaban. However, there was no documented evidence that the physician was notified of these recommendations, that the recommendations were carried out, or why they were not followed. During interview, nursing staff and the unit clerk stated that the CT brain was not done because the resident was in and out of the facility and hospital, and that the five-day monitor had not been sent for results and was still at the facility. The unit manager stated that recommendations would be relayed to the primary physician and carried out if approved, but she could not initially provide documentation showing whether the neurology and cardiology recommendations were followed or declined. Later, she provided a hospital CT head from a different event related to eyelid swelling and multiple falls, and stated that the CT brain and monitor recommendations were not approved by the primary doctor, while also confirming there was no documentation that the recommendations were relayed or declined. For the second resident, the discharge hybrid record showed diagnoses including cerebral infarction, palliative care, diabetes with retinopathy, aphasia, major depressive disorder, and unspecified psychosis. The current care plan reflected long-term care, but there was no documented evidence of a care plan for transfer to another facility. Social service documentation showed the resident was scheduled for transfer to another facility, transportation was arranged, and nursing was notified, but there was no documented evidence that the resident representative had prior notice of the transfer or was informed of the reason for transfer. The survey team also found that the facility’s most recent QAPI meeting did not identify the medical records/documentation concerns, and the facility policy provided did not include the regulatory requirements for records to be complete, accurately documented, readily accessible, and systematically organized.
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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