Deficiency Records for Hanover Hall For Nursing and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Hanover Hall For Nursing and Rehabilitation. 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? |
|---|---|---|---|---|
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-09-28 | 2023-11-06 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-09 | 2023-05-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-09 | 2023-05-24 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-03-30 | 2023-05-16 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-03-30 | 2023-05-16 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2023-03-30 | 2023-05-16 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-03-30 | 2023-05-16 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-03-30 | 2023-05-16 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-03-30 | 2023-05-16 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-03-30 | 2023-05-16 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-30 | 2023-05-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-30 | 2023-05-16 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-03-30 | 2023-05-16 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-03-30 | 2023-05-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-30 | 2023-05-16 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-03-30 | 2023-05-16 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-03-30 | 2023-05-16 | N |
| Provide or obtain dental services for each resident. | Health | 2023-03-30 | 2023-05-16 | 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 | 2023-03-30 | 2023-05-16 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-30 | 2023-05-16 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-03-30 | 2023-05-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-30 | 2023-05-16 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-03-30 | 2023-05-16 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-03-30 | 2023-05-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-03-06 | 2023-04-24 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-03-06 | 2023-04-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-06 | 2023-04-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-06 | 2023-04-24 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2023-03-06 | 2023-04-24 | 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 | 2022-09-13 | 2022-10-25 | Y |
| 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 | 2022-09-13 | 2022-10-25 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-07 | 2022-06-18 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-04-07 | 2022-06-18 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-04-18 | 2022-05-30 | N |
| Have correct number of accessible exits for each story. | Fire Safety | 2022-04-18 | 2022-05-30 | 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 | 2022-04-18 | 2022-05-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-18 | 2022-05-30 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-07 | 2022-05-08 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-04-07 | 2022-05-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-07 | 2022-05-08 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-04-07 | 2022-05-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-07 | 2022-05-08 | 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 | 2022-04-07 | 2022-05-08 | N |
| Provide or obtain dental services for each resident. | Health | 2022-04-07 | 2022-05-08 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-04-07 | 2022-05-08 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2022-04-07 | 2022-05-08 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-11-04 | 2021-12-11 | Y |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2021-11-04 | 2021-12-11 | Y |
| Use approved construction type or materials. | Fire Safety | 2021-04-22 | 2021-06-18 | N |
| Have correct number of accessible exits for each story. | Fire Safety | 2021-04-22 | 2021-06-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-04-22 | 2021-06-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-22 | 2021-06-18 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-04-22 | 2021-06-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-04-22 | 2021-06-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-04-22 | 2021-06-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-04-22 | 2021-06-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-08 | 2021-05-08 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-04-08 | 2021-05-08 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-04-08 | 2021-05-08 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-08 | 2021-05-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-04-08 | 2021-05-08 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-04-08 | 2021-05-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-08 | 2021-05-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-04-08 | 2021-05-08 | 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 | 2021-04-08 | 2021-05-08 | N |
