Stratford Manor Rehabilitation and Care Center

In the surveyor’s words

From the most serious findings on record at Stratford Manor Rehabilitation and Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF760Mar 8, 2022

  Based on observation, interview, record review, and other pertinent facility documentation, it was determined that the facility failed to ensure: a.) 2 of 3 anti-[CONDITION(S)] medications ([MEDICATION(S)] and [MEDICATION(S)]) ordered upon discharge from the hospital were appropriately discussed with the Physician for re-order, reconciled, received from the Provider Pharmacy, and administered in accordance with hospital discharge instructions for a resident with recent [CONDITION(S)] activity (Resident #163), and b.) an anti-[CONDITION(S)] medication ([MEDICATION(S)]) was available and administered as ordered for a second resident with a history of [CONDITION(S)] disorders (Resident #27). […]

• No harm, potential for more than minimal, widespreadF812Apr 24, 2024

  Based on observation, interview, record review and policy review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness, and b.) failed to maintain the kitchen environment and equipment 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: On 4/18/24 at 9:52 AM, in the presence of the Dietary Director (DD), the surveyor observed the following: 1. In the food preparation area, the surveyor observed seven of seven oven knobs and the oven handle soiled with a brown colored substance, which was able to be lifted with the tip of a pen. […]

• No harm, potential for more than minimal, patternF628Sep 22, 2025

  Based on interview, record review, and review of facility provided documents, it was determined that the facility failed to ensure a.) the bed hold-policy that was provided to the Resident or Resident's Representative (RR) included information about the reserve bed payment policy plan, the explanation of the right to appeal the transfer, and the Resident and/or RR's information for 2 of 2 residents (Residents #2 and #16) reviewed for hospital transfer and b.) the transfer or discharge was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution, including the discharge summary for 1 of 1 resident (Resident #15) reviewed for transfer.The deficient practice was evidenced by the following: 1.On 9/15/25 at 1:24 PM,… […]

• No harm, potential for more than minimal, patternF711Apr 24, 2024

  Based on interview and record review, it was determined that the facility failed to ensure that the residents' primary physician signed and dated monthly physician orders to ensure that the residents' current medical regimen was appropriate. This deficient practice was observed for 6 of 24 residents (Resident #12, #16, #22, #111, #13, and #62) reviewed and occurred over several months. This deficient practice was evidenced by the following: 1. A review of the hybrid medical record for Resident #12 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for January 2024, February 2024, and March 2024. The monthly physician's orders were not in the chart and there was no electronic signature. 2. […]

• No harm, potential for more than minimal, patternF755Apr 24, 2024

  REPEAT DEFICIENCY Based on observation, interview and record review, it was determined that 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 a medication Alendronate Sodium (Fosamax)(a medication used to treat and prevent osteoporosis/low bone mass) from October 2023 until surveyor inquiry. This occurred for one (1) of 11 residents, (Resident #25), reviewed for medication management. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. […]