A list of the most recent deficiencies for Hanover Nursing Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-11-20 | 2023-12-13 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-11-20 | 2023-12-13 | Y |
| Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. | Health | 2023-09-27 | 2023-12-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-27 | 2023-12-13 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-09-27 | 2023-12-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-27 | 2023-12-13 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-09-27 | 2023-12-13 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-09-27 | 2023-12-13 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-09-27 | 2023-12-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-27 | 2023-12-13 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-09-27 | 2023-12-13 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-08 | 2023-04-17 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-03-08 | 2023-04-17 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-03-08 | 2023-04-17 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-03-08 | 2023-04-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-08 | 2023-04-17 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-03-08 | 2023-04-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-08 | 2023-04-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-03-08 | 2023-04-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-08 | 2023-04-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-03-08 | 2023-04-17 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-03-08 | 2023-04-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-08 | 2023-04-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-08 | 2023-04-17 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-03-08 | 2023-04-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-08 | 2023-04-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-23 | 2023-04-10 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-02-27 | 2023-04-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-27 | 2023-04-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-02-27 | 2023-04-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-27 | 2023-04-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-27 | 2023-04-05 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-02-27 | 2023-04-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-27 | 2023-04-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-27 | 2023-04-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-02-27 | 2023-04-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-02-27 | 2023-04-05 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-02-27 | 2023-04-05 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-02-27 | 2023-04-05 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-02-27 | 2023-04-05 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-02-27 | 2023-04-05 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-02-27 | 2023-04-05 | N |
| 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. | Health | 2023-02-27 | 2023-04-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-19 | 2023-02-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-30 | 2023-01-20 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-30 | 2023-01-20 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-11-30 | 2023-01-20 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-11-30 | 2023-01-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-09 | 2022-09-08 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-06-01 | 2022-07-01 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-06-01 | 2022-07-01 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-06-01 | 2022-07-01 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-06-01 | 2022-07-01 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-06-01 | 2022-07-01 | N |
| Develop a communication plan. | Fire Safety | 2022-06-01 | 2022-07-01 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-06-01 | 2022-07-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-06-01 | 2022-07-01 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2022-06-01 | 2022-07-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-06-01 | 2022-07-01 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-06-01 | 2022-07-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-06-01 | 2022-07-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-04 | 2022-06-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-04 | 2022-06-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-04 | 2022-06-04 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-05-04 | 2022-06-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-05-04 | 2022-06-04 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-05-04 | 2022-06-04 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-20 | 2022-05-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-05 | 2022-02-22 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-12-13 | 2022-01-12 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-11-23 | 2022-01-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-13 | 2021-10-29 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-05-17 | 2021-08-24 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-05-17 | 2021-08-24 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-05-17 | 2021-08-24 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-05-17 | 2021-08-24 | N |
| Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Fire Safety | 2021-05-17 | 2021-08-24 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-05-17 | 2021-08-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-17 | 2021-08-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-17 | 2021-08-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-05-17 | 2021-08-24 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-05-17 | 2021-07-26 | N |
| Meet other general requirements. | Fire Safety | 2021-05-17 | 2021-07-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-05-17 | 2021-07-26 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-05-17 | 2021-07-26 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-05-17 | 2021-07-26 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-05-17 | 2021-07-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-05-17 | 2021-07-26 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-05-17 | 2021-07-26 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-05-17 | 2021-07-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-05-17 | 2021-07-26 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-05-17 | 2021-07-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-05-17 | 2021-07-26 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-05-17 | 2021-07-26 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2021-05-17 | 2021-07-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-17 | 2021-07-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-17 | 2021-07-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-05-17 | 2021-07-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-05-17 | 2021-06-15 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-05-03 | 2021-06-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-03 | 2021-06-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-03 | 2021-06-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-05-03 | 2021-06-02 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-05-03 | 2021-06-02 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-05-03 | 2021-06-02 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-05-03 | 2021-06-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-03 | 2021-06-02 | N |
