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Complaint Investigation

Hanover Hall For Nursing And Rehabilitation

November 19, 2025 · Hanover, PA · 267 Frederick Street
Citations 2
CMS Rating 2/5
Beds 151
Provider ID 395016
Healthcare Facility
Hanover Hall For Nursing And Rehabilitation
Hanover, PA  ·  View full profile →
Inspection Summary

HANOVER HALL FOR NURSING AND REHABILITATION in HANOVER, PA — inspection on November 19, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0677
Quality of Life and Care Deficiencies
Potential for More Than Minimal Harm

Review of Resident 3's clinical record documented diagnoses that included dementia with behavioral disturbances, vascular parkinsonism (cause by brain damage and symptoms may include gait disturbance, slowness, stiffness and cognitive issues), and adjustment disorder with mixed anxiety and depressed mood with disturbance of emotions and conduct.

Further clinical record review revealed that Resident 3 was dependent, two-person physical assistance due to combativeness, for bathing/showering and was scheduled for showers on Tuesdays and Fridays on evening shift.

Review of task documentation revealed she received a shower on October 31st, 2025, and was washed up at the sink on October 28th, 2025, and November 7th, 2025.The clinical record failed to include documentation for bathing on October 21st and 24th, 2025, and November 4th, 11th, and 14th, 2025.

During an interview with the Nursing Home Administrator and DON on November 19, 2025, at 3:15 PM, it was revealed she felt that Resident 3 has had bathing completed but staff hadn't documented it. It was also revealed that Resident 3 had verbal and physical behaviors, as well as being up for several days. If the Resident is sleeping after long periods of being awake, the staff will let her sleep. 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

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Hanover Hall for Nursing and Rehabilitation

267 Frederick Street Hanover, PA 17331

SUMMARY STATEMENT OF DEFICIENCIES

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a urinalysis and urine culture and sensitivity were completed timely for one of two resident records reviewed (Resident 4).Findings include:Review of Resident 4 clinical record revealed diagnoses that included history of urinary tract infection.Review of Resident 4's physician orders included: obtain UA (urinalysis) C&S (culture and sensitivity) one time only for 2 Days, started October 7, 2025, at 5:30 PM.

Review of the Medication Administration Record documented 15 (resident refused and requested the urine be collected on day shift) on December 7th, 2025.Further review of the physician orders included obtain UA/ C&S discontinue once completed, started October 13th, 2025, at 3:00 PM, and discontinued October 13th, 2025, at 4:39 PM.

Review of the urinalysis report dated October 13, 2025, at 6:20 PM, revealed the specimen was taken October 13th, 2025, at 10:19 AM, was received at 3:57 PM, and the result was available at 4:22 PM.

The results revealed urine appeared turbid, trace protein, and 2+ glucose and protein; however, there was no bacteria present.

Due to no bacteria, a C & S was not preformed.

During an interview with the Nursing Home Administrator and Director of Nursing on November 19, 2025, at 3:30 PM, it was confirmed that Resident 4's urine sample should've been collected prior to October 13th, 2025, per physician order. It was also revealed that the Resident had requested the urine be collected on day shift.

The Nurse completed the Medication Administration Record and didn't extend the order to include the following day; therefore, the order appeared like it was completed in the electronic record.28 Pa code 211.12 (d)(1)(5) Nursing Services

Facility ID:

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 HANOVER, PA, (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 HANOVER HALL FOR NURSING AND REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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