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Inspection visit

Health inspection

CHANDLER HALL HEALTH SERVICESCMS #3953054 citations on this visit
4 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, clinical record review and staff interview, it was determined that the facility failed to notify a resident's responsible party of a significant weight loss for one of two sampled residents with weight changes. (Residents 35) Findings include: Review of the facility policy entitled, Weight Policy, dated August 17, 2022, revealed that any unplanned significant weight changes were to be reported to the physician and the resident's representative. Clinical record review revealed that Resident 35 had diagnoses that included dysphagia following cerebral infarction and chronic kidney disease, stage 4. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had cognitive impairment and received tube feedings for his nutritional requirements. On April 26, 2023, the resident weighed 151 pounds (lbs). On May 25, 2023, Resident 35 weighed 138 lbs, an 8.61 percent weight loss in one month. There was no documented evidence that Resident 35's responsible party was notified of the significant weight loss. In an interview on July 7, 2023, at 12:18 p.m., the Director of Nursing stated there was no documented evidence that Resident 35's responsible party was notified of the significant weight loss. 28 Pa. Code 201.29(c) Resident rights. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 395305 Printed: 05/15/2026 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 395305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chandler Hall Health Services 99 Barclay Street Newtown, PA 18940 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 0584 Level of Harm - Potential for minimal harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment on three of three nursing units. (Nursing unit 1, 2 and 3) Residents Affected - Many Findings include: Observation during all days of the survey revealed the following: On unit 100 hall, one sit to stand transfer lift had diry wheels. On unit 200 hall, a utility room accordion door panel was broken and a chair scale had dirty wheels. On unit 300 hall, two sit to stand transfer lifts and one transfer lift equipment had dirty wheels. In the dining area, the resident's refrigerator had dried spillage stains on the crisper drawer glass and in one crisper drawer. 28 Pa Code: 201.18(b)(3) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395305 If continuation sheet Page 2 of 5 Printed: 05/15/2026 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 395305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chandler Hall Health Services 99 Barclay Street Newtown, PA 18940 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, review of policy and staff interview, it was determined that the facility failed to maintain sanitary conditions and store food properly in the kitchen. (Main Kitchen) Residents Affected - Many Findings include: Review of the facility policy entitled, Food Storage, dated August 17, 2022, revealed that products in storage were to be labeled with the date on delivery and once the product was opened the package was to be labeled with an opened and discard date. Observation during tour of the main kitchen dry storage room and refrigerator/freezers on July 5, 2023, at 11:10 a.m., revealed an open unwrapped 25 pound bag of whole grain brown rice received September 1, 2022, one open case of frozen egg rolls shipped September 15, 2022, one open case breaded chicken tenderloin received September 29, 2022, one jar of capers with no expiration date. The following items were past the expiration date: five boxes of grits, best by October 24, 2022, two bottles of white truffle oil with expiration dates of September 28, 2018, and September 27, 2019, one open low fat cottage cheese use by June 15, 2023, one low fat cottage cheese with best by date of June 23, 2023, two plastic containers of dressing, use by May 11, 2023, butter and chive mix use by July 1, 2023, half gallon whole milk, expired June 15, 2023, three wrapped beef packages, use by May 17, 2023. In the freezer there was a layer of frost on the outside of the food packages and boxes. Review of the policy entitled, Cleaning Instructions: Ovens, dated August 17, 2022, revealed that ovens were to be cleaned as needed and according to the cleaning schedule at least once every two weeks. Spills and food particles were to be removed after each use. Observations on July 5, 2023, at 11:10 a.m., and July 6, 2023, at 11:05 a.m., revealed both ovens had a grease buildup on the inside walls, the inside of the doors, and on the oven racks. There were three stained oven racks stored on the floor behind a cookware rack and next to the ovens. Review of the policy entitled, Cleaning Instructions: Deep Fat Fryer, dated August 17, 2022, revealed that the deep fat fryer oil was to be changed at least every 10 times the fryer was used. When the oil color changed to a dark brown, the oil should be changed. Food particles were to be removed from the oil after each use. Further, the baskets were to be cleaned by running them through the dish machine and wiping them dry prior to storage. Observations on July 5, 2023, at 11:10 a.m., and July 6, 2023, at 11:05 a.m., revealed the deep fat fryer oil was dark brown and contained debris. Two fryer baskets were coated with grease and were stored on a stainless steel shelf that had grease and debris on it. Observations on July 5, 2023, at 11:10 a.m., and July 6, 2023, at 11:05 a.m., revealed the table top under the grill was wet with brown liquid spillage and debris. In an interview on July 5, 2023, at 11:10 a.m., the Food Service Director stated that food was to be dated prior to storage and disposed of when items expired. The Food Service Director stated there was no documentation to support that cleaning was scheduled or being completed per facility policy. 28 Pa.Code 201.18(b)(1)(3) Management. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395305 If continuation sheet Page 3 of 5 Printed: 05/15/2026 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 395305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chandler Hall Health Services 99 Barclay Street Newtown, PA 18940 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 0812 28 Pa. Code 207.2(a) Administrator's responsibility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395305 If continuation sheet Page 4 of 5 Printed: 05/15/2026 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 395305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chandler Hall Health Services 99 Barclay Street Newtown, PA 18940 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, it was determined that the facility failed to properly contain refuse in a sanitary manner. Residents Affected - Few Findings include: Observation on July 5, 2023, at 11:10 a.m., revealed that there was trash and debris, including clear plastic bags and paper on the ground around the trash compactor. The recycling dumpster contained cardboard and the lid was open. 28 Pa. Code 207.2(a) Administrator's responsibility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395305 If continuation sheet Page 5 of 5

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Citations

4 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0580GeneralS&S Dpotential for harm

    F580 - Notification of Changes

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  • 0584GeneralS&S Cno actual harm

    F584 - Safe Environment

    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

  • 0812GeneralS&S Fpotential for harm

    F812 - Food safety requirements

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

  • 0814GeneralS&S Dpotential for harm

    F814 - Food Safety Requirements

    Dispose of garbage and refuse properly.

FAQ · About this visit

Common questions about this visit

What happened during the July 7, 2023 survey of CHANDLER HALL HEALTH SERVICES?

This was a inspection survey of CHANDLER HALL HEALTH SERVICES on July 7, 2023. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at CHANDLER HALL HEALTH SERVICES on July 7, 2023?

Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) tha..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.