West Orange, NJ

Stratford Manor Rehabilitation And Care Center

4-star overall rating with 3-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

787 Northfield Ave, West Orange, NJ

(973) 731-4500

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

131

Certified beds

Average residents

125

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Mb Healthcare

Operator or chain grouping

Approved since

1970-10-15

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

11 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.59

Registered nurse staffing · state 0.69 · national 0.68

LPN hours / resident day

0.75

Licensed practical nurse staffing · state 0.94 · national 0.87

Aide hours / resident day

2.07

Nurse aide staffing · state 2.23 · national 2.35

Total nurse hours

3.41

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.34

RN + LPN hours · state 1.62 · national 1.54

Weekend hours

2.95

Weekend nurse staffing · state 3.45 · national 3.43

Weekend RN hours

0.40

Weekend registered nurse coverage · state 0.49 · national 0.47

Physical therapist

0.10

Reported PT staffing · state 0.11 · national 0.07

Adjusted RN hours

0.57

CMS adjusted RN staffing hours

Adjusted total hours

3.27

CMS adjusted total nurse staffing hours

Case-mix index

1.43

Higher values indicate more complex resident acuity

RN turnover

24%

Annual RN turnover · state 39% · national 45%

Total nurse turnover

25%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

5,555

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

35.78

Composite VBP score used to determine payment impact.

Payment multiplier

0.9894

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.22

Baseline 19.37% · Performance 20.87% · Measure score 1.22 · Achievement 1.22 · Improvement 0

Healthcare-associated infections

2.72

Baseline 7.19% · Performance 7.02% · Measure score 2.72 · Achievement 2.72 · Improvement 0.25

Total nurse turnover

Baseline 40.91% · Performance 24.00% · Measure score 10 · Achievement 10 · Improvement 9

Adjusted total nurse staffing

0.37

Baseline 2.92 hours · Performance 3.17 hours · Measure score 0.37 · Achievement 0 · Improvement 0.37

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.5%	10.72% 0.8 pts worse	No Different than the National Rate · Eligible stays 131 · Observed rate 14.5% · Lower 95% interval 8.2%
Discharge to community	54.91%	50.57% 4.3 pts better	No Different than the National Rate · Eligible stays 127 · Observed rate 42.52% · Lower 95% interval 42.67%
Medicare spending per beneficiary	1.54	1.02 0.5 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 176 · Denominator 176
Falls with major injury	0.57%	0.77% 0.2 pts better	Numerator 1 · Denominator 176
Discharge self-care score	65.96%	53.69% 12.3 pts better	Numerator 62 · Denominator 94
Discharge mobility score	47.87%	50.94% 3.1 pts worse	Numerator 45 · Denominator 94
Pressure ulcers or injuries, new or worsened	1.7%	2.29% 0.6 pts better	Numerator 3 · Denominator 176 · Adjusted rate 1.23%
Healthcare-associated infections requiring hospitalization	7.02%	7.12% 0.1 pts better	No Different than the National Rate · Eligible stays 91 · Observed rate 7.69% · Lower 95% interval 3.97%
Staff COVID-19 vaccination coverage	2.62%	8.2% 5.6 pts worse	Numerator 5 · Denominator 191
Staff flu vaccination coverage	99.01%	42% 57 pts better	Numerator 200 · Denominator 202
Discharge function score	58.51%	56.45% 2.1 pts better	Numerator 55 · Denominator 94
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 77 · Denominator 77
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 49 · Denominator 49
Resident COVID-19 vaccinations up to date	3.41%	25.2% 21.8 pts worse	Numerator 3 · Denominator 88

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.7	2.1 0.6 pts worse	1.9 0.8 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.7 · Expected 1.9 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.8	1.1 0.3 pts better	1.8 1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	97.5%	93.0% 4.5 pts better	93.4% 4.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 96.2% · Q3 97.0% · Q4 98.0% · 4Q avg 97.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.2%	97.2% 1 pts better	95.5% 2.7 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.2%
Percentage of long-stay residents experiencing one or more falls with major injury	0.8%	2.4% 1.6 pts better	3.3% 2.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	4.6%	11.4% 6.8 pts better	11.4% 6.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 3.4% · Q3 2.2% · Q4 6.5% · 4Q avg 4.6%
Percentage of long-stay residents who lose too much weight	2.7%	4.6% 1.9 pts better	5.4% 2.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 4.1% · Q3 0.0% · Q4 1.1% · 4Q avg 2.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	6.4%	19.0% 12.6 pts better	19.6% 13.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 6.9% · Q3 7.1% · Q4 6.2% · 4Q avg 6.4%
Percentage of long-stay residents who received an antipsychotic medication	4.2%	13.5% 9.3 pts better	16.7% 12.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 2.9% · Q3 4.0% · Q4 5.3% · 4Q avg 4.2% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	4.2%	9.8% 5.6 pts better	16.3% 12.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 7.3% · Q3 2.2% · Q4 4.6% · 4Q avg 4.2% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	6.3%	9.7% 3.4 pts better	14.9% 8.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 9.2% · Q3 3.4% · Q4 6.0% · 4Q avg 6.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.3%	0.7% 0.4 pts better	1.0% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.5%	0.8% 0.3 pts better	1.7% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	5.1%	15.9% 10.8 pts better	19.8% 14.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 6.9% · Q3 5.4% · Q4 4.4% · 4Q avg 5.1%
Percentage of long-stay residents with pressure ulcers	5.7%	6.0% 0.3 pts better	5.1% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 7.2% · Q3 6.3% · Q4 4.3% · 4Q avg 5.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	97.1%	78.7% 18.4 pts better	81.7% 15.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 96.0% · Q3 96.7% · Q4 97.1% · 4Q avg 97.1%
Percentage of short-stay residents who had an outpatient emergency department visit	3.6%	8.2% 4.6 pts better	12.0% 8.4 pts better	Short Stay · 20240701-20250630 · Adjusted 3.6% · Observed 3.7% · Expected 11.5% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.3%	1.2% 0.9 pts better	1.6% 1.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 0.3% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	94.5%	80.1% 14.4 pts better	79.7% 14.8 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 94.5%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	24.3%	25.4% 1.1 pts better	23.9% 0.4 pts worse	Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 29.0% · Expected 28.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-22 · Fire 2025-09-22

6 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2024-04-24 · Fire 2024-04-24

12 health deficiencies

Top issue: Pharmacy Service (4 deficiencies)

2 fire-safety deficiencies

Top issue: Services (1 deficiency)

Cycle 3 Health 2022-03-08 · Fire 2022-03-08

5 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-09-22

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2025-10-24

F · Potential for more than minimal harm 2025-09-22

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2025-10-24

F · Potential for more than minimal harm 2025-09-22

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-10-24

D · Potential for more than minimal harm 2025-09-22

K347 · Smoke Deficiencies

Fire Safety

Properly provide smoke detection systems in areas open to corridors.

Corrected 2025-10-24

F · Potential for more than minimal harm 2024-04-24

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-05-09

F · Potential for more than minimal harm 2024-04-24

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-05-09

D · Potential for more than minimal harm 2022-03-08

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2022-04-14

D · Potential for more than minimal harm 2022-03-08

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2022-04-29

D · Potential for more than minimal harm 2022-03-08

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2022-04-14

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-09-22

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2025-10-24

D · Potential for more than minimal harm 2025-09-22

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2025-10-24

D · Potential for more than minimal harm 2025-09-22

F636 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Corrected 2025-10-24

D · Potential for more than minimal harm 2025-09-22

F712 · Nursing and Physician Services Deficiencies

Health

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Corrected 2025-10-24

D · Potential for more than minimal harm 2025-09-22

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2025-10-24

D · Potential for more than minimal harm 2025-09-22

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-10-24

F · Potential for more than minimal harm 2024-04-24

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-05-13

E · Potential for more than minimal harm 2024-04-24

F711 · Nursing and Physician Services Deficiencies

Health

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Corrected 2024-05-17

E · Potential for more than minimal harm 2024-04-24

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-05-17

E · Potential for more than minimal harm 2024-04-24

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2024-05-17

E · Potential for more than minimal harm 2024-04-24