Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Lord Chamberlain Manor Nursing & Rehabilitation Ce during CMS and state inspections, most recent first.
A resident with acute respiratory failure, septic shock, intact cognition, and high ADL assistance needs was discharged home with documentation stating that skilled home care services (nursing, PT, OT, and HHA) had been arranged. Post-discharge, the listed home care agency reported having no record of the resident and not serving the resident’s geographic area, and another RN from the agency confirmed no referral was received. The DNS acknowledged the resident should have had home care but was unsure about service start timing or agency coverage, and the SW confirmed that no home care services were provided and could not explain why a referral was not made or confirmed, contrary to the facility’s own transfer and discharge policy.
A resident with a history of stroke, atrial fibrillation, and antiphospholipid syndrome did not receive Coumadin therapy as ordered, with missed doses and delayed or missing INR monitoring. Documentation was inconsistent, and staff did not act on subtherapeutic INR results in a timely manner, resulting in significant medication errors and failure to maintain the therapeutic INR range.
Two residents with significant medical histories, including atrial fibrillation and recent hospitalizations, were prescribed Coumadin and received the medication for several weeks. Despite physician orders for anticoagulation therapy and required INR monitoring, the facility did not develop or document care plans addressing anticoagulation therapy or bleeding risk for either resident, as required by facility policy. Interviews with the DON, Administrator, and an RN confirmed the omission and the lack of explanation for why the care plans were not completed.
A resident with atrial fibrillation and a history of TIA did not consistently receive Coumadin as ordered, due to multiple transcription errors by LPNs and incorrect dosing entries by an APRN. Missed doses and delays in obtaining new orders led to the resident's INR frequently falling outside the therapeutic range, contrary to physician instructions and facility protocol.
A resident with confusion and a recent femur fracture, identified as an elopement risk and wearing a wander guard, was able to leave the facility unsupervised after a Dietary Aide opened a non-alarmed cafe door without consulting nursing staff. The resident was later found at a nearby gas station without the wander guard and refused to return, requiring EMS intervention.
A resident with dementia and a high fall risk exhibited increased agitation and combative behavior, including medication refusal and the need for constant redirection. Although a physician was notified of agitation on admission and a PRN medication was ordered, there was no evidence that the physician was informed of the resident's further behavioral escalation during the night shift, contrary to facility policy. This lapse occurred prior to the resident experiencing an unwitnessed fall and subsequent hospital transfer.
A resident with multiple chronic conditions experienced vaginal bleeding and repeatedly refused to use an ordered AVAP device at bedtime. Nursing staff documented these events and communicated among themselves and to respiratory therapy, but failed to notify the medical provider in a timely manner as required. This resulted in a delay in provider awareness and intervention for significant changes in the resident's condition.
A resident with a surgical abdominal wound was transferred to the hospital for infection and was not allowed to return to the facility after the hospital cleared them for discharge. Nursing staff reported being instructed not to readmit the resident, though the supervisor did not recall giving this direction. The facility's administrator confirmed that residents should be permitted to return within 48 hours, and the facility's policy supports resident return after hospitalization.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy tube and a PICC line, despite the resident's diagnoses of severe sepsis and infection due to an orthopedic prosthetic device. The resident required substantial assistance and was receiving intravenous therapy. There was no EBP signage or PPE outside the resident's room, and the nursing assistant was unaware of the need for additional precautions. The oversight was acknowledged by the LPN and DNS, who confirmed that the resident should have been on EBP due to the presence of indwelling medical devices.
A resident with a history of leg amputation and other medical conditions was not treated with dignity when requesting wheelchair leg rests before a dialysis appointment. Despite the resident's request, an LPN attempted to transport the resident without the leg rests, contrary to facility protocol. The facility's policy required leg rests unless the resident requested otherwise, and the Administrator acknowledged the importance of listening to residents' requests.
A resident with a fracture and muscle weakness was unable to use the standard call bell due to stiff buttons, despite being alert and oriented. The facility had alternative call bell options, but they were not provided, and the policy did not address procedures for residents unable to use a standard call bell. This led to the resident attempting to get out of bed without assistance.
A facility failed to include dialysis needs and medication monitoring in a baseline care plan for a resident with end-stage renal disease and bipolar disorder. Despite physician orders for dialysis and mood stabilization medication, the care plan omitted these critical elements due to staff oversight. The Director of Nursing acknowledged the oversight, which contravened the facility's policy requiring comprehensive care plans within 48 hours of admission.
A resident with congestive heart failure and muscle weakness required two-person assistance for bed mobility, as per physician's orders. However, a nurse aide assisted the resident alone, leading to discomfort and dissatisfaction. The aide believed the resident could assist themselves, despite the care plan specifying total dependence. The facility's policy mandates adherence to care plans, which was not followed in this case.
A facility failed to ensure correct medication administration for a resident with NPO status and a gastrostomy tube. Despite the resident's condition requiring all medications to be administered via the tube, several orders were incorrectly transcribed as 'by mouth' in the EHR. Staff interviews revealed a lack of clarification and correction of these orders, contrary to facility policy.
The facility failed to implement physician-ordered safety measures for two residents. One resident with a history of seizures was observed without required bumper guards and floor mats, despite orders and a care plan specifying these precautions. Another resident, with multiple health issues, was not wearing heel booties as ordered to offload heels, despite staff signing off on compliance. Facility policies on seizure precautions and physician orders were not effectively followed, leading to these deficiencies.
A facility failed to provide appropriate assistance during a resident's transfer, leading to a fall, and did not conduct a smoking assessment for another resident, who continued to smoke on the premises. The facility also failed to enforce its no-smoking policy, resulting in cigarette waste accumulation.
A resident with acute respiratory failure and heart failure did not receive oxygen as per physician orders, leading to a deficiency in care. Despite orders for continuous oxygen at 2 liters via nasal cannula, the resident was observed without oxygen on multiple occasions. Staff, including an LPN and the DNS, were unable to explain the presence of multiple conflicting oxygen orders or why continuous oxygen was signed off when not administered. The facility's policy for reviewing physician orders was not followed, resulting in the deficiency.
A facility failed to identify and monitor a resident's AV fistula, essential for dialysis care. The resident, dependent on dialysis, was not assessed for the fistula upon admission, and the baseline care plan lacked documentation of its presence. Facility policies require monitoring of AV fistulas every shift, but this was not done due to oversight in entering batch orders and MAR instructions.
A facility failed to ensure a resident receiving Zyprexa had an appropriate diagnosis and monitoring. The resident, admitted with anxiety/depression disorder, was prescribed Zyprexa for anxiety, which is not an appropriate diagnosis. Orthostatic BP monitoring was delayed, and AIMS testing was not conducted. The resident was unaware of the medication's purpose, and the DNS confirmed anxiety disorder was not a valid diagnosis for antipsychotic use.
A facility failed to provide a resident with the requested alternative menu option, despite the resident's care plan identifying nutritional status and diet as a concern. The resident, who had dysphagia, depression, and gastro-esophageal reflux disease, reported not receiving requested menu substitutions. An observation confirmed the resident received pudding instead of yogurt. Interviews revealed that dietary and nurse aides did not consistently check dietary slips and meal tray contents, with one aide stating she was often too busy to verify trays.
A resident admitted with sepsis, chronic kidney disease, and type 2 diabetes was not offered an influenza vaccine, nor was there documentation of refusal or prior immunization. The facility's policy required offering the vaccine to all eligible residents, but this was not adhered to, as revealed in an interview with an RN.
Failure to Arrange and Confirm Home Care Services Prior to Discharge
Penalty
Summary
The facility failed to ensure that a resident was discharged with arranged home care services as identified in the discharge planning process. The resident had diagnoses including acute respiratory failure and septic shock, an admission MDS showing a BIMS score of 14 (intact cognition), and required maximal assistance with toileting and transfers, with a care plan indicating assistance with ADLs. The facility’s discharge summary documented that the resident was being discharged home and would receive skilled services, including nursing, PT, OT, and home health aide, and a nursing note stated the resident was discharged home with home care services. However, interviews and record review revealed that the home care agency listed on the discharge summary had no record of the resident and did not service the resident’s home area. A second RN from the home care agency reported they never received a referral for the resident. The DNS acknowledged the resident should have been discharged home with home care services but was unsure when services were to start and did not know if the agency served the resident’s area. The social worker confirmed that the listed home care agency reported the resident never received services after discharge and could not identify why a referral was not made and confirmed to a home care agency, despite the facility’s transfer and discharge policy directing that discharge be planned with resident participation and assistance in adjusting to the new living environment.
Failure to Maintain Therapeutic INR Levels and Timely Coumadin Management
Penalty
Summary
The facility failed to ensure that a resident receiving Coumadin (Warfarin) therapy had their INR levels maintained within the physician-ordered therapeutic range of 2.5 to 3.5. The hospital discharge summary specified Coumadin dosing and required INR monitoring every other day, with dose adjustments as needed. However, clinical record review revealed that INR tests were not consistently performed as ordered, and Coumadin doses were not always administered according to the prescribed schedule. There were multiple days when the resident did not receive any Coumadin, and INR results were frequently below the therapeutic range without timely intervention or dose adjustment. Documentation on the Coumadin Tracking Form was inconsistent and sometimes contained conflicting information regarding current doses, new orders, and next INR test dates. There were also instances where new orders were not obtained or acknowledged by a physician or APRN, and INR results were not acted upon in a timely manner. Interviews with clinical staff confirmed that the resident's INR levels were not maintained within the therapeutic range, and that the management of Coumadin therapy was not efficient or consistent with the facility's own Coumadin protocol policy. The resident had significant medical conditions, including cerebral infarct with hemiplegia, atrial fibrillation, and antiphospholipid syndrome, all of which increased the importance of maintaining therapeutic anticoagulation. Despite these risks, the facility did not provide adequate monitoring or management of the resident's Coumadin therapy, resulting in significant medication errors as identified by both facility staff and external reviewers. The deficiency was cited as Immediate Jeopardy due to the failure to maintain the ordered therapeutic INR range and to ensure timely and appropriate medication administration and monitoring.
Failure to Timely Develop Care Plans for Residents on Anticoagulation Therapy
Penalty
Summary
The facility failed to develop and implement timely care plans for anticoagulation therapy for two residents who were prescribed Coumadin (Warfarin) following their admission. Both residents had medical histories that included conditions such as atrial fibrillation, cerebral infarct with hemiplegia/hemiparesis, antiphospholipid syndrome, and transient ischemic attack, and were ordered to receive daily Coumadin with specific instructions for INR monitoring and dose adjustments. Despite these orders and the administration of Coumadin over several weeks, review of the clinical records and resident care plans revealed that neither resident had a care plan addressing anticoagulation therapy or the associated risk for bleeding, as required by facility policy and the Coumadin protocol. Interviews with the DON, Administrator, and an RN confirmed that it was the responsibility of the nursing or MDS team to ensure care plans reflected resident needs and treatment plans, and that comprehensive care plans should be completed within the required timeframe after admission. The facility was unable to provide documentation of care plans for anticoagulant use for either resident and acknowledged that such care plans should have been in place. The reason for the omission could not be identified during the interviews.
Failure to Accurately Administer and Manage Coumadin Therapy
Penalty
Summary
The facility failed to ensure that Coumadin was administered and managed according to physician orders and the resident's therapeutic INR goal. A resident with a history of atrial fibrillation and transient ischemic attack was admitted with orders for Coumadin and a target INR range of 2.0 to 3.0. Multiple errors were identified in the transcription and administration of Coumadin orders, resulting in missed doses on several occasions. Specifically, LPNs transcribed Coumadin orders to start on incorrect dates, causing the resident to miss scheduled doses on three separate days. Additionally, there were inconsistencies and delays in obtaining new Coumadin orders when INR results were outside the therapeutic range. On several occasions, the resident's INR was either above or below the target range, but no new orders were documented or implemented in a timely manner. There was also a documented instance where an APRN intended to increase the Coumadin dose but incorrectly entered a lower dose, which was then administered to the resident. Facility documentation and interviews confirmed that the resident's Coumadin therapy was not consistently managed to maintain the INR within the prescribed range. The facility's Coumadin protocol required accurate logging of INR results, current and new orders, and timely physician notification, but these procedures were not consistently followed. Both the APRN and physician acknowledged that Coumadin doses should not have been missed and that orders should have been transcribed accurately.
Failure to Prevent Elopement of At-Risk Resident Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident identified as being at risk for elopement was able to leave the facility without staff knowledge or supervision. The resident, who had a history of confusion and was assessed as a fall and elopement risk, was admitted with a left femur fracture and had a wander guard bracelet placed on their wrist. Despite these precautions, the resident expressed a desire to leave the facility, was noted to be exit-seeking, and required standby assistance for mobility. On the day of the incident, the resident entered the facility's cafe and requested to go outside. A Dietary Aide, unaware of the resident's elopement risk and without confirming with nursing staff, assisted by opening the cafe side door, which was not equipped with a wander guard alarm system. The resident exited through this door and was later found at a gas station across a four-lane road, approximately 0.3 miles from the facility. At the time of discovery, the resident no longer had the wander guard bracelet and refused to return to the facility, requiring EMS intervention for transport. Facility documentation and staff interviews confirmed that the Dietary Aide did not check for the presence of the wander guard or consult with nursing staff before allowing the resident outside. The lack of adequate supervision and the absence of an alarm system on the cafe door directly contributed to the resident's unsupervised exit from the facility.
Failure to Notify Physician of Resident's Increased Agitation
Penalty
Summary
The facility failed to ensure timely physician notification regarding a resident's increased agitation. The resident, who had dementia with behavioral disturbance and a history of falls, was admitted following a recent hospitalization for a fall and was identified as a high fall risk. Nursing documentation showed that the resident exhibited increased agitation, restlessness, and combative behavior during the night shift, including refusing medications and requiring constant redirection. Although the physician was notified of agitation on the day of admission and a PRN Trazodone order was obtained, there was no evidence that the physician was notified of the further increase in agitation and combative behavior observed during the early morning hours of the following day. Facility policy required that the physician, resident, and family/legal representative be informed of changes in condition. Interviews with staff and the physician confirmed that the physician was not notified of the resident's increased agitation on the morning in question, despite expectations and policy. The lack of timely notification occurred prior to an unwitnessed fall, after which the resident was found on the floor with a head injury and transferred to the hospital.
Failure to Notify Medical Provider of Change in Condition and Treatment Refusals
Penalty
Summary
The facility failed to ensure timely notification of a medical provider regarding a resident's change in condition. The resident, who had multiple diagnoses including COPD, sleep apnea, chronic cellulitis, morbid obesity, and congestive heart failure, was admitted with orders for continuous oxygen and use of an AVAP (a type of CPAP) device. The resident also had an unstageable pressure injury and required mechanical lift transfers. On one occasion, the resident experienced vaginal bleeding, which was noted by nursing staff and assessed by an RN, but there was no documentation that the MD or APRN was notified of this change until over eight hours later, when a PA was finally contacted and orders were obtained. Additionally, the resident repeatedly refused to use the AVAP device at bedtime and overnight, as documented by multiple LPNs. Although these refusals were communicated among nursing staff and to the respiratory therapist, there was no evidence that the APRN or MD was notified of the refusals, despite facility expectations and physician orders requiring such notification. Interviews with staff confirmed that refusals of the AVAP device were not consistently reported to the medical provider, and the acting DON stated that such refusals should have been communicated to the APRN. The lack of timely notification to the medical provider regarding both the vaginal bleeding and the repeated refusals to use the AVAP device constituted a failure to inform the provider of significant changes in the resident's condition and non-compliance with physician orders. This deficiency was confirmed through clinical record review, facility documentation, and staff interviews.
Failure to Permit Resident Return After Hospitalization
Penalty
Summary
A resident with a diagnosis of abdominal wound due to intestinal perforation and small bowel obstruction was transferred to the hospital for a wound infection. The resident had a physician's order for specific wound care and was noted to be alert and oriented with a surgical wound requiring ongoing treatment. Documentation showed that the wound was stable at the time of the last evaluation, and the care plan included instructions to provide wound care per treatment orders. Following the hospital transfer, the resident was not readmitted to the facility despite the hospital indicating the resident was ready for discharge back to the facility. An RN reported receiving instructions during shift change not to accept the resident's return, although the supervisor did not recall giving such a directive. The facility's administrator stated that residents are permitted to return within 48 hours per federal guidelines and was unaware of the reason for the denial. The facility's bed hold policy allows residents to return after hospitalization, but the resident was not permitted to do so in this instance.
Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Devices
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy tube and a peripherally inserted central catheter (PICC). The resident, who was cognitively intact, required substantial assistance with mobility and was dependent on toileting. Diagnosed with severe sepsis, septic shock, and an infection due to an internal orthopedic prosthetic device, the resident was receiving intravenous therapy and had a feeding tube. Despite these conditions, there was no posted signage for EBP outside the resident's room, and the nursing assistant providing care was unaware of the need for additional precautions, as the care card did not indicate EBP, and no personal protective equipment (PPE) was available outside the room. The oversight was further confirmed by a Licensed Practical Nurse (LPN) and the Director of Nursing Services (DNS), who acknowledged that the resident should have been on EBP due to the presence of indwelling medical devices. The facility's policy required an order for EBP and the implementation of signage and PPE for residents with such devices. However, the necessary steps were not taken upon the resident's admission, and the charge nurse responsible for the admission did not obtain a physician's order or ensure the placement of EBP signage and PPE. This lapse in protocol was identified as an oversight by the DNS and the Infection Preventionist.
Failure to Provide Dignified Care for Resident Requesting Wheelchair Leg Rests
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity when requesting wheelchair footrests. Resident #374, who had a medical history including acquired absence of the left leg below the knee, generalized muscle weakness, end-stage renal disease, and hypertension, was observed sitting in a wheelchair without leg rests. The resident, who was alert and oriented but forgetful, requested the surveyor to inform the nurse about the need for leg rests before being transported to a dialysis appointment. Despite the request, LPN #5 attempted to push the wheelchair forward without informing the resident, intending to transport the resident to the physical therapy room to obtain the leg rests. LPN #5 acknowledged that the resident should have had the leg rests applied before being transported. The facility's protocol, as confirmed by the Administrator and Occupational Therapist, required that residents in wheelchairs have leg rests applied unless the resident requested otherwise. The facility policy also stated that extremities should be supported once a resident is transferred to a wheelchair. The Administrator recognized that residents have a right to be listened to and treated with dignity, and LPN #5 should have adhered to the resident's request for leg rests.
Failure to Provide Appropriate Call Bell for Resident
Penalty
Summary
The facility failed to accommodate the physical limitations of Resident #525 by not providing an appropriate call bell system. Resident #525, who had a fracture of the right femur, a history of falling, and muscle weakness, was unable to use the standard call bell due to the stiffness of the buttons. Despite being alert and oriented, the resident could not press the call bell to call for assistance, as observed during multiple interviews and observations with staff. The facility had alternative call bell options, such as manual handheld bells and soft touch pads, but these were not provided to the resident. The deficiency was further highlighted by the fact that the facility's policy did not address procedures for residents unable to use a standard call bell. Interviews with staff revealed that while the call bell's functionality was checked upon admission, there was no assessment of the resident's ability to use it. Despite the availability of alternative call bells, they were not stocked on the unit and required a request to Maintenance for delivery. The failure to provide an appropriate call bell led to Resident #525 attempting to get out of bed without assistance, as noted in a nursing progress note.
Failure to Address Dialysis Needs in Baseline Care Plan
Penalty
Summary
The facility failed to implement a baseline care plan that addressed the immediate needs of a resident with end-stage renal disease who was dependent on renal dialysis. Upon admission, the resident had diagnoses including type 2 diabetes with diabetic chronic kidney disease and bipolar disorder. Physician orders indicated that the resident required dialysis at an outpatient facility three times a week and was prescribed Lamotrigine for mood stabilization. However, the Baseline Resident Care Plan (RCP) did not include the resident's dialysis needs or medication monitoring, despite addressing other categories such as activities of daily living, elimination, pain, falls, and behavior. Interviews and record reviews revealed that the omission of dialysis and psychotropic medication evaluation in the Baseline RCP was due to staff oversight. The Director of Nursing Services acknowledged that the Baseline RCP should have included goals, weights, diet, and other elements specific to dialysis. The facility's policy mandates that a baseline care plan be completed within 48 hours of admission, including resident goals, services, treatments, and a summary of medications and dietary instructions. The failure to include these critical elements in the care plan represents a deficiency in meeting the resident's immediate needs.
Failure to Provide Required Assistance for Bed Mobility
Penalty
Summary
The facility failed to ensure that a resident, who was admitted with diagnoses including congestive heart failure, respiratory failure, muscle weakness, and obesity, received the required assistance with bed mobility according to physician's orders. The resident, who was non-ambulatory and bed/chair-bound, was identified as needing the assistance of two staff members for bed mobility. However, during an observation, a nurse aide assisted the resident alone, contrary to the physician's order and the care plan, which specified the need for two-person assistance. The resident expressed discomfort and dissatisfaction with the assistance provided, noting that the inconsistency in the number of aides assisting made them feel annoyed. Interviews with the nurse aide and the physical therapist revealed that the aide was aware of the resident's need for assistance but chose to assist alone, believing the resident could help themselves by holding onto the bed rails. The physical therapist emphasized the importance of following care plans and orders to prevent potential injury to the resident. The facility's policy for positioning and repositioning residents requires staff to check the care plan and follow the specified number of staff required for assistance, which was not adhered to in this instance.
Failure to Ensure Correct Medication Administration Route for NPO Resident
Penalty
Summary
The facility failed to ensure that medication orders for a resident with a gastrostomy tube and NPO (nothing by mouth) status were correctly documented with the appropriate route of administration. The resident, who was admitted with conditions including dysphagia and GERD, had multiple physician orders indicating medications to be given by mouth, despite the NPO status. These discrepancies were found in the electronic health record (EHR) and were not corrected by the nursing staff responsible for transcribing the orders. Interviews with the resident and staff, including an APRN and an LPN, confirmed that the resident was aware of their NPO status and that all medications and nutrition should be administered via the gastrostomy tube. The APRN acknowledged that the orders were transcribed incorrectly into the EHR and that the original handwritten orders did not specify a route of administration. The LPN admitted to not realizing the error due to being accustomed to oral administration of medications and did not seek clarification from the prescriber. The Director of Nursing Services (DNS) also confirmed the oversight and emphasized that all medication orders should specify a route of administration. The facility's policy requires that any discrepancies in medication orders be clarified and corrected by the nursing supervisor. However, this protocol was not followed, leading to the incorrect transcription of medication orders for the resident.
Failure to Implement Physician-Ordered Safety Measures
Penalty
Summary
The facility failed to implement physician-ordered safety measures for a resident with seizure precautions. The resident, who had a history of seizures, encephalopathy, and hemiplegia following a stroke, was observed multiple times without the required bumper guards on bed rails and floor mats at the bedside. Despite a care plan and physician's orders specifying these precautions, staff did not ensure their implementation. Observations revealed that the necessary equipment was either misplaced or not used, and the nurse aide care card lacked the updated information about these safety measures. Additionally, a Licensed Practical Nurse (LPN) admitted to signing off on the Treatment Administration Record (TAR) without verifying the presence of the safety equipment. Another deficiency involved a resident with acute respiratory failure, congestive heart failure, and chronic kidney failure, who was supposed to have heel booties applied to offload heels while in bed or a recliner chair. Observations showed that the resident was not wearing heel booties as ordered, despite staff signing off on the Medication Administration Record (MAR) indicating compliance. An LPN acknowledged the oversight and admitted to not checking the application of heel booties before signing the MAR. The Director of Nursing Services (DNS) confirmed the requirement for heel booties but could not explain the staff's failure to apply them. The facility's policies on seizure precautions and physician orders were not effectively followed, leading to these deficiencies. The seizure precautions policy directed the use of padded side rails for residents at risk, while the policy on physician orders lacked specificity regarding the application of heel booties. These lapses in following physician orders and facility policies resulted in the failure to provide appropriate care and safety measures for the residents involved.
Deficiencies in Resident Transfer Assistance and Smoking Policy Enforcement
Penalty
Summary
The facility failed to provide appropriate assistance during the transfer of a resident, identified as Resident #374, who had significant mobility and cognitive impairments. The resident, who required maximum assistance of two staff members for pivot transfers due to conditions such as acquired absence of the left leg below the knee and generalized muscle weakness, was transferred by a single nurse aide. This resulted in the resident's right leg giving out and the resident falling to the floor. The nurse aide did not adhere to the care plan and occupational therapy recommendations, which specified the need for two staff members during transfers. Another deficiency was identified concerning Resident #624, who was admitted with conditions including sepsis and type 2 diabetes mellitus. The facility failed to conduct a smoking assessment as part of the initial admission assessment, despite the resident's regular smoking activity. The resident informed staff of their smoking habits, yet the facility, which was a non-smoking environment, was unaware of the resident's smoking until it was brought to their attention during the survey. The smoking assessment form was left blank, and the resident continued to smoke on facility grounds without proper supervision or intervention. Additionally, the facility did not ensure the proper disposal of cigarette materials, as evidenced by the observation of over 100 cigarette butts in the mulch surrounding the seating area by the water fountain. The facility's policy stated it was a non-smoking environment, yet the grounds were littered with cigarette waste, indicating a lack of enforcement of the no-smoking policy and inadequate maintenance of the designated smoking area.
Failure to Administer Oxygen Per Physician Orders
Penalty
Summary
The facility failed to administer oxygen to a resident as per physician orders, leading to a deficiency in respiratory care. The resident, who had diagnoses including acute respiratory failure with hypoxia, heart failure, and muscle weakness, had multiple physician orders for oxygen administration. These orders included applying oxygen as needed to maintain oxygen saturations over 92%, applying oxygen at 15 liters via nasal cannula or non-rebreather mask if oxygen saturation fell below 90%, and administering oxygen at 2 liters via nasal cannula at baseline every shift. However, observations on multiple occasions identified the resident sitting without oxygen, despite the order for continuous oxygen at 2 liters via nasal cannula. Staff, including an LPN and the DNS, were unable to explain why the resident had three different oxygen orders or why staff was signing off that the resident was on continuous oxygen when they were not. The LPN indicated a misunderstanding of the orders, believing the resident was on an as-needed basis and did not require continuous oxygen. The DNS confirmed the presence of three different current oxygen orders and noted that staff should have consulted with the Nursing Supervisor or Respiratory Therapist to clarify and discontinue unnecessary orders. The facility's policy required physician orders to be reviewed every 24 hours for accuracy, but discrepancies were not addressed, leading to the deficiency.
Failure to Monitor Dialysis Fistula
Penalty
Summary
The facility failed to properly identify and monitor a resident's arteriovenous (AV) fistula, which is crucial for dialysis care. The resident, who has end-stage renal disease and relies on dialysis, was not properly assessed for the presence and condition of the AV fistula upon admission. The baseline care plan and admission nursing assessment did not document the existence of the AV fistula, nor did they include any monitoring or assessment protocols for it. This oversight was confirmed through interviews with the resident, nursing staff, and the Director of Nursing Services (DNS), who acknowledged that the necessary batch orders for dialysis residents were not entered due to staff oversight. The facility's policies require that AV fistulas be monitored every shift for bruit and thrill, with documentation on the Medication Administration Record (MAR) or Treatment Administration Record (TAR). However, these assessments were not conducted or documented for the resident. The Nursing Supervisor and DNS both confirmed that the lack of documentation and assessment was due to the MAR not indicating the need to check the fistula, and the batch orders not being entered. This failure to adhere to the facility's Hemodialysis and A-V Fistula Policies resulted in the deficiency noted in the report.
Inappropriate Use and Monitoring of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident receiving an antipsychotic medication, Zyprexa, had an appropriate diagnosis and monitoring. Resident #674 was admitted with diagnoses including anxiety/depression disorder, chronic obstructive pulmonary disease, and breast cancer. Despite being alert, oriented, and having a pleasant mood with no unwanted behaviors, a physician's order was made to administer Zyprexa for anxiety disorder, which is not an appropriate diagnosis for its use. The facility did not conduct orthostatic blood pressure monitoring as ordered until seven days after the initial order. Additionally, progress notes from APRNs failed to identify an appropriate diagnosis for Zyprexa, and the attending physician's review did not address the reason for its use. The facility also neglected to perform an Abnormal Involuntary Movement Scale (AIMS) test as recommended by a pharmacy consultant and did not document behavior monitoring. Interviews with the Director of Nursing Services (DNS) and Resident #674 revealed that the resident was unaware of the reason for taking the antipsychotic medication, and the DNS acknowledged that anxiety disorder was not a supporting diagnosis for its use. The facility's policy on antipsychotic medication use specifies that such medications should only be used when necessary to treat specific conditions and should not be used for symptoms like mild anxiety or restlessness.
Failure to Provide Requested Menu Substitutions
Penalty
Summary
The facility failed to provide the requested alternative menu option for Resident #625, who had diagnoses including dysphagia, depression, and gastro-esophageal reflux disease. The resident's care plan identified nutritional status and diet as a concern, with interventions to provide diet and fluids as ordered. However, during an interview, the resident reported not receiving the menu substitutions they had requested. An observation confirmed that the resident received pudding instead of the requested yogurt. Interviews with dietary and nurse aides revealed a lack of consistent checking of dietary slips and meal tray contents, with one nurse aide stating she was often too busy to verify the trays, leading to the resident not receiving the correct meal items.
Failure to Offer Influenza Vaccine to Resident
Penalty
Summary
The facility failed to offer an influenza vaccine to Resident #624, who was admitted in October 2024 with diagnoses including sepsis, chronic kidney disease, and type 2 diabetes. The Baseline Resident Care Plan identified the resident as being at risk for falls, with interventions such as the use of a call bell. The admission nursing assessment noted the resident was alert and oriented, with a right hip incision. Physician orders included administering the Pneumovax 23 vaccine for pneumonia prophylaxis, but there was no order for an influenza vaccine. An interview with RN #1 revealed that the admitting nurse, charge nurse, and infection preventionist were responsible for offering the influenza vaccine and documenting the resident's acceptance or refusal. However, there was no documentation of the resident being offered the vaccine, declining it, or having previous immunization evidence for the 2024-2025 flu season. The facility's policy required offering the influenza vaccine to all residents without medical contraindications or previous immunization evidence between October 1st and March 31st, which was not followed in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 528 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Stratford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lord Chamberlain Nursing & Rehabilitation Center | 0 mi | ★★★★★ | 0 | 0 |
| Masonicare At Bishop Wicke Health & Rehabilitation | 2.4 mi | ★★★★★ | 14 | 0 |
| Civita Care Center At West River | 2.6 mi | ★★★★★ | 0 | 0 |
| Gardner Heights Health Care Center, Inc | 2.7 mi | ★★★★★ | 5 | 0 |
| Civita Care Center At Milford | 2.8 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Lord Chamberlain Manor Nursing & Rehabilitation Ce.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.