Lord Chamberlain Manor Nursing & Rehabilitation Ce

In the surveyor’s words

From the most serious findings on record at Lord Chamberlain Manor Nursing & Rehabilitation Ce, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Sep 23, 2025

  Based on review of clinical record, facility documentation, facility policy, and interviews for one of three residents (Resident #1) reviewed for medication errors, the facility failed to ensure Coumadin therapy to adequately maintain INR levels as ordered, failed to monitor the INR levels timely, and failed to act on the INR results timely in accordance with physician orders. The failures resulted in a finding of Immediate Jeopardy. The finding includes: The Hospital Discharge summary dated [DATE] directed Coumadin (Warfarin) (anticoagulant, used to prevent blood clots), 4 milligrams (mg) daily and to maintain an International Normalized Ratio (INR, blood test to measure how long blood takes to clot, used to monitor the effectiveness Coumadin) between 2.5 and 3.5. […]

• No harm, potential for more than minimal, widespreadF880May 22, 2026

  Based on observations, interviews, review of clinical record and facility policy for 1 of 1 resident (Resident #9) reviewed for glucometer use, the facility failed to perform hand hygiene before and after glucometer use and for 3 of 3 residents (Resident #14, Resident #65 and Resident #70) reviewed for pressure ulcers, the facility failed to ensure residents with a pressure ulcer had enhanced barrier precautions (EBP) implemented and failed to ensure appropriate infection control practices were followed during a dressing change. Additionally, for Resident #65, the facility failed to wear the appropriate personal protective equipment (PPE) during a dressing change and failed to ensure personal care items on 4 of 4 nursing units were labeled, covered and properly stored. […]

• No harm, potential for more than minimal, patternF726May 22, 2026

  Based on facility documentation, facility policy and interviews for review of 2 of 2 Registered Nurse (RN) (RN #2 and RN #3) personnel files, the facility failed to ensure new hire RNs had the knowledge and skills required for care of residents prior to removal from orientation and allowing them to work shifts independently as the RN Supervisor. The findings include: Review of the Facility Assessment Tool dated 1/13/26 identified the following education was provided upon hire: resident rights, abuse, infection control (hand hygiene, isolation, use of PPE, MRSA/VRE/CDI precautions, environmental cleaning), person-centered care, change in condition, cultural competency, end of life care, death and dying, activities of daily living (bathing, bed-making, bedpan, dressing, feeding, nail care,… […]

• No harm, potential for more than minimal, patternF812May 22, 2026

  Based on tour of the dietary department, interviews, and facility policies, the facility failed to ensure food items were labeled and dated, expired food items were discarded, facial hair was covered, and ovens were clean. The findings include: A tour of the Dietary Department with the Food Service Director (FSD) on 5/17/26 at 9:20 AM identified the following:1a. A tray of sandwiches (15) in the reach in refrigerator was undated. The FSD indicated that the sandwiches were just made that morning. Post inquiry, sandwiches were removed and dated. b. Sliced ham covered with plastic wrap was located on a shelf in the walk-in refrigerator and dated 5/13/26 (4 days old). Post inquiry, the lunch meat was discarded. c. […]

• No harm, potential for more than minimal, patternF880Oct 25, 2024

  Based on observations, interviews, review of the clinical record, facility documentation, and facility policy for 1 of 5 residents (Resident #326) reviewed for infection control, the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy (feeding) tube and a peripherally inserted central catheter (PICC). The findings include: Resident #326's diagnoses included severe sepsis with septic shock, infection and inflammatory reaction due to internal orthopedic prosthetic device and elevated white blood cell count. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #326 was cognitively intact and required substantial/maximal assistance with bed mobility and transfers and was dependent with toileting. […]