Lord Chamberlain Nursing & Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF580Oct 25, 2024

  Based on review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #42) reviewed for a change in condition, the facility failed to ensure the physician/APRN was notified of the unavailability of a medication resulting in hospitalization , and for 2 of 2 residents (Resident #33 and Resident #38) reviewed for edema, the facility failed to notify the physician of weight increase of 5 pounds (lbs.) in one week for a resident with diagnosis of Congestive Heart Failure (CHF). The findings included: 1. […]

• Actual harm, isolatedF684Oct 25, 2024

  Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #42) reviewed for change in condition, the facility failed to administer the resident's medication as prescribed to ensure the resident was free of a significant medication error. The findings include Resident #42's diagnoses included Chronic inflammatory demyelinating polyneuritis (disorder of the autonomic nervous system), and dysarthria and anarthria.( a condition that results in complete or partial loss of speech due to a severe motor speech impairment). A physician's order date 7/25/24 directed to administer immunoglobulin 10% every 4 weeks via intravenously. […]

• Actual harm, isolatedF760Oct 25, 2024

  Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #42) reviewed for change in condition, the facility failed to ensure the resident was free of a significant medication error. The findings include: .Resident #42's diagnoses included Chronic inflammatory demyelinating polyneuritis (disorder of the autonomic nervous system), and dysarthria and anarthria. A physician's order date 7/25/24 directed to administer immunoglobulin 10% every 4 weeks. An Inter-Agency Referral Report dated 7/25/24 indicated the resident was to receive immunoglobulin 10% every 4 weeks intravenously. […]

• Actual harm, isolatedF689Dec 22, 2023

  Based on record reviews and staff interviews for one of three sampled residents (Resident #1) who required two (2) person assistance with turning and repositioning when in bed, the facility failed to ensure two (2) staff members were present at the bedside when the resident was turned onto a side to prevent the resident from sliding off the bed and sustaining a fracture of the right tibia and fibula. The findings include: Resident #1's diagnoses included abnormality of gait and mobility, dementia, and anxiety. […]

• No harm, potential for more than minimal, patternF585Jun 23, 2026

  Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 5 residents (Resident #13 and Resident #126) reviewed for grievances, the facility failed to ensure the grievance procedure was followed. The findings include: 1. Resident #13 had diagnoses that included dementia, diabetes, chronic migraines.The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #13 was severely cognitively impaired, did not use a mobility device, required setup or clean-up assistance with eating, partial/moderate assistance with oral hygiene and chair/bed transfers, substantial/maximal assistance with toileting hygiene, was independent with bed mobility and walking.The Resident Care Plan (RCP) dated 2/3/26 identified Resident #13 was at risk for impaired… […]