Lord Chamberlain Manor
Inspection Findings
F-Tag F0657
F 0657 Level of Harm - Minimal harm or potential for actual harm
(MDS), and will be updated by Nursing and/or the IDT as needed. Review of the undated Coumadin Protocol Policy directed in part, all residents receiving Coumadin will have a care plan for risk for bleeding related to anticoagulation therapy.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/23/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lord Chamberlain Manor
7003 Main Street Stratford, CT 06614
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
therapeutic INR goal). 9/18/2025, the INR level was 1.3 (under the therapeutic level by 0.7). the prior Coumadin order was for 1.5 mg. New orders were obtained for Coumadin 10 mg for one (1) dose with an INF on 9/19/2025, and APRN #2 signed acknowledgement of the tracking form. 9/19/2025, the INR level was 1.8 (under the therapeutic level by 0.2). A new order was obtained for Coumadin 10 mg for one (1) dose, then 6 mg for the following two (2) days, an INR on 9/22/2025, and APRN #2 signed acknowledgement of the tracking form. 9/22/2025, the INR level was 3.3 (over the therapeutic level by 0.3).
New orders were obtained for Coumadin 5 mg, and an INR to be drawn on 9/24/2025, and APRN #2 signed acknowledgement of the tracking form. Record review identified Resident #2 missed doses of Coumadin on 8/12, 8/22 and 9/2/2025. Additional review identified the INR results were under the therapeutic level 8/18 and 8/19, 9/2, 9/12, 9/15, 9/18, and 9/19/2025. INR results were within the therapeutic level on 8/16/2025 with no new Coumadin orders obtained. Interview and clinical record review with APRN #2 on 9/18/2025 at 12:15 PM identified Resident #2's received Coumadin for atrial fibrillation with an INR goal range between 2.0 to 3.0 for a therapeutic level. Interview identified from 8/12 through 9/15/2025 Resident #2 missed Coumadin doses and should not have missed any doses. Further APRN identified the INR was not maintained within the therapeutic range in accordance with physician orders.
APRN #2 stated on 9/15/2025 she had intended to increase Resident #2's Coumadin dose by 1.5 mg (in addition to the 5 mg dose for a total of 6.5 mg), but instead, incorrectly entered the new Coumadin order as 1.5 mg (instead of 6.5 mg). APRN #2 stated it was an error on her part. Interview and clinical record review with MD #2 on 9/23/2025 at 12:30 PM identified maintaining the INR results can be tricky and it is better to be high results than low. Review identified the INR results under the therapeutic level as described above.
MD #2 stated the orders should have been transcribed accurately, and a resident on Coumadin should receive Coumadin daily, unless contraindicate such as the INR too high. Review of the undated facility Coumadin Protocol Policy directed in part, the facility will implement a log and will indicate the INR date and result, current and new Coumadin orders, next INR ordered, and date/time of physician/APRN notification.
The Policy further directed, the INR therapeutic range must be determined.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/23/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lord Chamberlain Manor
7003 Main Street Stratford, CT 06614
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0760
F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
day of Coumadin 7 mg was administered and was then discontinued. The Coumadin Tracking Form failed to identify new orders were obtained for Coumadin and the next INR due date. No Coumadin was administered on 8/29, 8/30 and 8/31/2025. 9/1/2025 INR level was 1.2 (under the goal INR by 1.3). APRN #1 ordered Coumadin 10 mg daily, with next INR due on 9/4/2025, and APRN #1 signed acknowledgement of the Tracking Form. Coumadin 10 mg was administered on 9/1 and 9/2/2025, and Resident #1 was transferred to the hospital on 9/3/2025 for an unrelated event.Review identified the INR was not maintained within the ordered therapeutic level of 2.5 to 3.5, and Resident #1 did not receive any Coumadin doses on thirteen (13) days (8/14, 15, 18, 19, 20, 21, 22, 23, 24, 26, 29, 30 and 8/31/2025). Interview and clinical
record review with APRN #2 on 9/18/2025 at 12:15 PM identified Resident #1 received Coumadin for atrial fibrillation and antiphospholipid syndrome, and the therapeutic goal INR range was between 2.5 to 3.5, to reduce the risk of a blood clot. APRN #2 reviewed the Coumadin orders and INR results from 8/8 through 9/3/2025 and stated the INR levels were not maintained within the therapeutic level, which put Resident #1 at a higher risk for blood clots. APRN #2 further stated that she would consider the errors in the INR management a significant medication error.Interview and clinical record review with MD #2 on 9/23/2025 at 12:30 PM identified Resident #1 was at an increased risk of blood clots due to the INR was not maintained within the therapeutic range, and the Coumadin should have been ordered to maintain the INR of 2.5 to 3.5. Interview failed to identify why the INR levels were not maintained at the ordered levels. Interview with
the DON, Administrator, and RN #2 on 9/23/2025 at 3:30 PM identified the INR results were ordered to be maintained between 2.5 and 3.5. The DON, Administrator, and RN #2 were unable to provide documentation Resident #1's Coumadin regime was managed efficiently to maintain the ordered therapeutic INR goal. Interview failed to identify why the INR levels were not maintained at the ordered levels. Review of the undated facility Coumadin Protocol Policy directed in part, the facility will implement a log and will indicate the INR date and result, current and new Coumadin orders, next INR ordered, and date/time of physician/APRN notification. The Policy further directed, the INR therapeutic range must be determined.
Event ID:
Facility ID:
If continuation sheet
LORD CHAMBERLAIN MANOR in STRATFORD, CT inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in STRATFORD, CT, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LORD CHAMBERLAIN MANOR or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.