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Deficiency Records for Hanover Health and Rehabilitation Center
A list of the most recent deficiencies for Hanover Health and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Hanover Health and Rehabilitation 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? |
|---|---|---|---|---|
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-06-30 | 2023-07-20 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-06-30 | 2023-07-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-12 | 2022-12-06 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-10-12 | 2022-12-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-12 | 2022-12-06 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-12 | 2022-12-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-12 | 2022-09-13 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-05-05 | 2022-06-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-05 | 2022-06-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-05 | 2022-06-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-04-28 | 2022-06-07 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-04-28 | 2022-06-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-28 | 2022-06-07 | 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 | 2022-04-28 | 2022-06-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-04-28 | 2022-06-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-28 | 2022-06-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-28 | 2022-06-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-04-28 | 2022-06-07 | 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 | 2022-04-28 | 2022-06-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-28 | 2022-06-07 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2022-04-28 | 2022-06-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-20 | 2022-06-07 | N |
| Meet other general requirements. | Fire Safety | 2019-07-26 | 2019-11-19 | N |
| Use approved construction type or materials. | Fire Safety | 2019-07-26 | 2019-11-19 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-07-26 | 2019-11-19 | 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 | 2019-07-26 | 2019-11-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-26 | 2019-11-19 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-07-26 | 2019-11-19 | 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 | 2019-08-07 | 2019-10-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-07 | 2019-09-21 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-08-07 | 2019-09-21 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-08-07 | 2019-09-21 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-08-07 | 2019-09-21 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-08-07 | 2019-09-21 | N |
| Respond appropriately to all alleged violations. | Health | 2019-08-07 | 2019-09-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-08-07 | 2019-09-21 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-08-07 | 2019-09-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-07 | 2019-09-21 | 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 | 2019-08-07 | 2019-09-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-07 | 2019-09-21 | N |
| Provide activities to meet all resident's needs. | Health | 2019-08-07 | 2019-09-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-07 | 2019-09-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-07 | 2019-09-21 | 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 | 2019-08-07 | 2019-09-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-08-07 | 2019-09-21 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-08-07 | 2019-09-21 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-08-07 | 2019-09-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-07 | 2019-09-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-07 | 2019-09-21 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2019-08-07 | 2019-09-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-07 | 2019-09-21 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-08-07 | 2019-09-21 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-08-07 | 2019-09-21 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-08-07 | 2019-09-21 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-08-07 | 2019-09-21 | 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 | 2019-07-26 | 2019-09-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-26 | 2019-09-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-26 | 2019-09-11 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-07-26 | 2019-09-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-07-26 | 2019-09-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-26 | 2019-09-11 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-07-26 | 2019-09-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-26 | 2019-09-11 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-07-26 | 2019-09-11 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-03-05 | 2018-04-06 | 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 | 2018-03-05 | 2018-04-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-03-05 | 2018-04-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-03-05 | 2018-04-06 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-03-05 | 2018-04-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-03-05 | 2018-04-06 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-03-05 | 2018-04-06 | 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 | 2018-03-05 | 2018-04-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-03-05 | 2018-04-06 | N |
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