Hanover Healthcare Center

Inspectors wroteBased on observation, staff interviews and policy review, the facility failed to ensure its kitchen area was maintained in a clean and sanitary condition. This had the potential to affect 118 out of 119 residents who consumed meals from the facility's kitchen, as one resident (Resident #44) out of 119 residents received nothing by mouth. The census was 119.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent a fall while using a mechanical lift for Resident #123 and failed to ensure smoking interventions were followed for Residents #105 and #127. This affected one resident (Resident #123) of five residents reviewed for falls and affected two residents (Resident #105 and Resident #127) of four residents reviewed for smoking. The facility census was 113.

Inspectors wroteBased on medical record review, facility policy review, equipment and resident observations, and resident and staff interviews the facility failed to ensure appropriate respiratory care was provided for Residents #6, #12, #44, and #126. The affected four residents (Residents #6, #12, #44, and #126) of five residents reviewed for respiratory care. The facility census was 125. Findings Include: 1. Review of the medical record for Resident #126 revealed admission to the facility on [DATE] with diagnoses including acute respiratory failure, lung disease, bipolar disorder (a mood disorder leading to periods of depression and mania), depression, anxiety, smoker, diabetes, heart failure, end stage renal disease with hemodialysis, and fibromyalgia (chronic generalized pain). [...]

Inspectors wroteBased on observation, interview, taste test and recipe review, the facility failed to serve pureed foods at a smooth consistency for safe swallowing. This had the potential to affect six residents (#4, #15, #66, #73, #77, and #104) who were prescribed pureed diets of 118 residents who consumed meals from the facility's kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, clean, comfortable homelike environment for all residents. This affected three residents (#6, #45, and #85) reviewed for environment. The facility census was 113.

Inspectors wroteBased on record review, interview and facility policy review the facility failed to updated Preadmission Screening and Resident Reviews (PASRR) when residents had a change in condition. This deficient practice affected two residents (Resident #10 and #85) out of five residents reviewed for PASRR. The facility's census was 113. Findings Include:1. Review of Resident #10's medical record revealed an admission [DATE] with diagnoses including but not limited to schizoaffective disorder, anxiety, bipolar disorder, and major depressive disorder. Review of Resident #10's physician orders revealed an order dated 04/08/25 for antipsychotic medication Seroquel oral tablet 50 milligram (MG) give one tablet by mouth two times a day for schizoaffective disorder and an order dated 04/08/25 for Depakote oral capsule 125 MG give two capsules by mouth two times a day for bipolar disorder. [...]

Inspectors wroteBased on medical record review, facility policy review, and staff interviews the facility failed to provide a written baseline care plan to Residents #125 and Residents #126. The affected two residents (Resident #125 and Resident #126) of two residents reviewed for new admissions to facility in less than 14 days. The facility census was 125. Findings Include:1. Review of the medical record of Resident #125 revealed admission to facility on 03/06/26 with diagnoses including aftercare for surgical amputation of the left leg above the knee, heart failure, high blood pressure, end stage renal disease with dialysis, atrial fibrillation (irregular heart rate), lung disease, anxiety, gastric reflux, and delirium (confusion). [...]

Inspectors wroteBased on record review, observation, interview and facility policy review the facility failed to accommodate a resident with prosthetic arms which required assistive devices for self-feeding. This deficient practice affected one resident (Resident #105) out of one resident reviewed for activities of daily living. The facility census was 113. Findings Include:Review of Resident #105 medical record revealed admission date 02/07/23 with diagnoses including but not limited to dementia, traumatic amputation at right and left elbows, and Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #105's annual Minimum Data Set (MDS) dated [DATE] revealed Resident #105 was cognitively intact with a Brief Interview Mental Status (BIMS) score of 14 out of possible 15 and required staff assistance with setting up for eating. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide individualized activities of interest to Resident #18. This affected one resident (Resident #18) out of three residents reviewed for activities.

Inspectors wroteBased on medical record review, facility policy review, review of facility contracts, resident observation and interviews, and staff interview the facility failed to provide appropriate post dialysis evaluations for Residents #55 and #126. This affected two residents (Resident #55 and Resident #126) of two residents reviewed for dialysis care. There were 12 residents receiving dialysis care at the facility and the facility census was 125. Findings Include: 1. [...]

Inspectors wroteBased on record review, observations, interviews, and facility policy review the facility failed to maintain infection control by not disposing of used tracheostomy supplies and by not performing hand hygiene during incontinence care. These deficient practices affected two residents (Resident #12 and #44) out of nine residents reviewed for infection control. The facility census was 113. Findings Include: 1. Review of Resident #44's medical record revealed admission date 02/27/26 with diagnoses including but not limited to acute respiratory failure, epilepsy, kidney failure requiring hemodialysis, tracheostomy, and gastrostomy. Review of Resident #44's physician orders revealed an order dated 03/04/26 for tracheostomy care every shift. [...]

Inspectors wroteBased on record review, observations, interviews, and facility policy review the facility failed to ensure call lights within reach of residents. This deficient practice affected three residents (Residents #45, #112, and #116) out of three residents reviewed for call light use. The facility census was 113. Findings Include: 1. Review of Resident #112's medical record revealed admission date 11/22/24 with diagnoses including but not limited to dementia, depression and high blood pressure. Review of Resident #112's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #112 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of three out of possible 15 and required limited assistance from staff for completion of Activities of Daily Living (ADL) tasks. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the environment was maintained in a sanitary and working manner. This affected two residents (#12 and #71) out of thirteen residents reviewed for environmental concerns. The facility census was 113.

Inspectors wroteBased on medical record review and interview, the facility failed to provide sufficient staff to provide restorative nursing programs on a consistent basis. This affected three (Residents #26, #82, and #96) of three residents reviewed for restorative services. The facility identified 41 residents with orders for one or more restorative programs (Residents #1, #2, #3, #4, #6, #7, #11, #15, #18, #24, #26, #32, #34, #37, #41, #42, #43, #48, #51, #56, #61, #67, #68, #69, #70, #73, #75, #79, #81, #82, #86, #87, #90, #91, #92, #93, #94, #95, #96, #98 and #100).

Inspectors wroteBased on medical record review, policy review, and interview, the facility failed to ensure the nurse practitioner or physician were notified of a resident's low blood pressure reading prior to administering a medication with anti-hypertensive properties. This affected one (Resident #103) of three residents reviewed for medication administration.

Inspectors wroteBased on medical record review, policy review and interview, the facility failed to report allegations of misappropriation of money to the State Survey Agency. This affected one (Resident #49) of three residents reviewed for missing property.

Inspectors wroteBased on medical record review, policy review and interview, the facility failed to initiate a thorough investigation of allegations of a resident's stolen money. This affected one (Resident #49) of three residents reviewed for missing property.

Inspectors wroteBased on medical record review and interview, the facility failed to provide restorative nursing programs to maintain a resident's ability to ambulate. This affected two (Residents #26 and #82) of three residents reviewed for restorative services.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure medications were administered in accordance with physician orders and set parameters. This affected one (Resident #103) of three residents reviewed for medication administration.

Inspectors wroteBased on medical record review and interview, the facility failed to provide restorative range of motion (ROM) programs in accordance with physician orders for one (Resident #96) of three residents reviewed for restorative services.

Inspectors wroteBased on observation, review of physician orders, policy review, and interview, the facility failed to ensure medications were administered as ordered. Two medication errors were identified out of 27 opportunities resulting in a 7.4% medication error rate. This affected one (Resident #74) of two residents observed for medication administration.

Inspectors wroteBased on record review and interview, the facility failed to ensure the activities program was directed by a qualified professional. This had the potential to affect all 101 residents residing in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure infection control was maintained during incontinence care. This affected one resident (Resident #94) of three residents reviewed for incontinence care. The facility census was 100.

Inspectors wroteBased on review of the Payroll Based Journal (PBJ) report, review of schedules and time detail punches, and interview, the facility failed to ensure accuracy of information sent to Centers for Medicare and Medicaid (CMS). This had the potential to affect all 101 residents.

Inspectors wroteBased on observation, medical record review, interview, and facility policy review, the facility failed to ensure surgical wound treatments were completed per physician order. This affected one resident (#25) of three residents reviewed for wound care. The facility census was 96.

Inspectors wroteBased on medical record review and interview the facility failed to ensure laboratory testing (stools for occult blood) were obtained timely for Resident #101. This affected one resident (#101) of three residents reviewed for laboratory testing.

Inspectors wroteBased on observation, medical record review, interview and policy review the facility failed to maintain accurate medical records related to resident care. This affected one resident (#25) of three residents reviewed for wound care. The facility census was 96.

Inspectors wroteBased on observation, medical record reviews review of employee time clock punch reports, review of employee personnel files, review of facility Self-Reported Incidents (SRI), review of the facility assessment, facility policy review and interview, the facility failed to ensure all residents were free from staff to resident physical and/or emotional abuse. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm/injuries and psychosocial harm beginning on 09/05/24 at approximately 3:15 P.M. [...]

Inspectors wroteBased on observation, medical record reviews, review of facility Self-Reported Incidents (SRI), facility policy review and interview, the facility failed to ensure all allegations of physical and/or emotional abuse were reported immediately to the Administrator and State Survey Agency as required. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm/injuries and psychosocial harm beginning on 09/05/24 at approximately 3:15 P.M. when Activity Director (AD) #400 witnessed State Tested Nursing Assistant (STNA) #300 grab and force Resident #78 to sit in her specialty tilt-in-space wheelchair (a specialty wheelchair that offers both a tilting function and a reclining function and should not be considered an independent mobility device due to their size and weight) while yelling at the resident to sit down. [...]

Inspectors wroteBased on observation, medical record reviews, review of facility Self-Reported Incidents (SRI), facility policy review and interview, the facility failed to implement the facility abuse policy related to allegations of physical and emotional abuse by allowing alleged perpetrators continued access to the specified victims and/or other vulnerable residents and failed to timely initiate an investigation regarding the allegations of abuse. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm/injuries and psychosocial harm beginning on 09/05/24 at approximately 3:15 P.M. [...]

Inspectors wroteBased on observation, record review, interview, and policy review the facility failed to ensure newly hired employees were screened for tuberculosis (TB) prior to their first day of work, the blood glucose testing (BGT) machine was sanitized and disinfected appropriately after use, appropriate infection control was maintained during Resident #30's wound care, and staff donned appropriate personal protective equipment during tracheostomy care. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents who required staff assistance and/or were dependent on staff for activities of daily living including grooming, hygiene, eating and/or toileting received adequate and timely assistance to maintain their highest practicable well-being. This affected four residents (#4, #51, #64 and #214) of five sampled residents reviewed for activities of daily living. The facility census was 104.

Inspectors wroteBased on medical record review, review of the grievance/complaint log, review of the facility investigation, and interview with staff the facility failed to thoroughly investigate an allegation that a staff member took photographs of Resident #102 with her cell phone and failed to investigate a missing electric razor for Resident #64. This affected two residents (Resident #64 and #102) of three resident reviewed who filed formal concerns with the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Resident #13, who required setup assistance with meals, received the breakfast meal and was assisted with set up in a timely manner. This affected one (Resident #13) of thirty-one residents who required setup assistance on the secured memory care unit (SMCU). The census on the SMCU was 34.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #62 received adequate and timely treatment, including the administrative of laxative medication to address constipation. This affected one (Resident #62) of one resident reviewed for bowel regimen.

Inspectors wroteBased on medical record review and interview, the facility failed to provide vision care for Resident #27 in a timely manner. This affected one (Resident #27) of three residents reviewed for communication and sensory. Facility census was 104.

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to ensure skin impairment for Resident #64 was accurately assessed at the time of identification and to promote optimal healing. This affected one (Resident #64) of three residents reviewed for skin concerns. Facility census was 104.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, fire and police department report review, hospital record review, facility investigation review, policy review and interview, the facility failed to provide adequate supervision to Resident #112, who was admitted to the facility on [DATE] due to being an elopement risk with a need for placement on a secured unit, had verbalized his desire to leave the facility, was identified as an elopement risk on admission and received a recent diagnosis of dementia with psychosis, from exiting the second floor secured unit without staff knowledge. This affected one resident (#112) of four residents reviewed for staff supervision and elopement. The facility census was 110.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident and resident's representative's preferences were followed regarding having side rails on his bed. This affected one (Resident #113) of three residents reviewed for preferences. The facility census was 112.

Inspectors wroteBased on record review and interview, the facility failed to follow the direction of the telehealth nurse practitioner timely for a change in pain medication for a resident. This affected one (Resident #113) out of three residents reviewed for pain medication. The facility census was 112.

Inspectors wroteBased on record review and interview, the facility failed to ensure accurate documentation in the medical record for medication administration. This affected one (Resident #113) of three residents reviewed for accurate medical records. The facility census was 112.

Inspectors wroteBased on observation, interview, and policy review the facility failed to ensure a clean and sanitary kitchen. This had the potential to affect 104 residents receiving meals from the kitchen. The facility identified two residents (#162 and #163) who received nothing by mouth. The facility census was 106.

Inspectors wroteBased on observation, medical record review, and interviews, the facility failed to ensure safe smoking procedures. This affected one (Resident #235) of three (Residents #235, #258, and #259) residents reviewed for smoking. The facility identified 24 residents (#204, #205, #209, #212, #217, #221, #223, #224, #226, #228, #233, #234, #235, #237, #242, #243, #249, #255, #258, #259, #261, #273, #309, and #312) who smoked. The census was 114. Findings Include: Review of the medical record for Resident #235 revealed an admission date of 08/25/23. Diagnoses included but were not limited to multiple sclerosis, morbid obesity, bipolar disorder, major depressive disorder, anxiety disorder, post-traumatic stress disorder, and tobacco use. Review of the psychology note dated 09/11/23 for Resident #235 revealed she was having a multiple sclerosis flare up and was having hallucinations. [...]

Inspectors wroteBased on observations, interviews, facility census review, record review, facility policy review, and the Centers for Disease Control (CDC) guidance review, the facility failed to implement a comprehensive and effective infection control program to prevent the spread of COVID-19. This resulted in Immediate Jeopardy and the potential for actual harm, serious life-threatening complications, death beginning on [DATE] when the facility failed to implement effective and recommended infection control practices, including implementation of appropriate isolation and quarantine procedures to prevent the spread of COVID-19 within the facility when five residents (#81, #89, #98, #101 and #103), who did not have COVID-19, remained in rooms with residents (#80, #90, #97, #100 and #102), who had tested positive for COVID-19. [...]

Inspectors wroteBased on record review, interview, facility self-reported incident (SRI) review, and facility policy review the facility failed to implement their abuse policy to thoroughly investigate and timely report allegations of resident-to-resident abuse. This affected seven residents (#8, #16, #17, #34, #39, #84, and #112) of seven residents reviewed for abuse. The facility census was 111.

Inspectors wroteBased on record review, interview, facility self-reported incident (SRI) review, and facility policy review the facility failed to thoroughly investigate incidents of alleged resident-to-resident abuse. This affected seven residents (#8, #16, #17, #34, #39, #84, and #112) of seven Residents reviewed for abuse. The facility census was 111.

Inspectors wroteBased on record review, interview, facility self-reported incident (SRI) review, and policy review the facility failed to report an allegation of resident-to-resident abuse within the required time frames to the state agency. This affected two residents (#84 and #112) of seven residents reviewed for abuse. The facility census was 111.

Inspectors wroteBased on observation, staff interview, record review, review of facility infection control policies, and review of the Centers for Disease Control and Prevention (CDC) website the facility failed to implement infection control procedures for use of Personal Protective Equipment (PPE), isolation and COVID-19 screening. This had the potential to affect all 95 residents currently residing in the facility.

Inspectors wroteBased on record review, policy review and staff interview the facility failed to ensure residents and/or responsible parties received quarterly statements of resident personal funds account activity. This affected ten (Residents #1, #7, #12, #13, #14, #17, #19, #55, #63 and #72) of ten residents reviewed of 71 residents identified as having personal funds accounts managed by the facility. This had the potential to affect all but 24 (Residents #10, #30, #33, #36, #37, #39, #42, #46, #49, #50, #51, #53, #58, #62, #64, #70, #77, #80, #81, #86, #92, #295, #296 and #345) who did not have a personal funds account managed by the facility. The facility census was 95.

Inspectors wroteBased on funds account review, staff interview and policy review the facility failed to ensure residents who receive Medicaid benefits were notified when their account balance reached $200 less than the Supplemental Security Income (SSI) resource limit. This affected six (Residents #1, #7, #12, #17, #19, and #72) of 10 residents reviewed for personal funds accounts. The facility indicated they managed personal funds accounts for 71 residents. The facility census was 95.

Inspectors wroteBased on record review, interview and policy review, the facility failed to notify the Legal Guardian of Resident #90 prior to discharge to another facility. This affected one of two residents reviewed for discharge from the facility. The facility census was 95.

Inspectors wroteBased on record review, interview and policy review the facility failed to ensure ongoing treatment of pressure ulcers for Resident #46. This affected one (Resident #46) of seven residents reviewed for pressure and non pressure skin impairment. The facility identified seven residents with wounds as listed on the weekly wound report. The facility census was 95.

Inspectors wroteBased on observation, record review, interview and policy review the facility failed to ensure the ongoing assessment of the resident's condition and monitoring for complications before and after hemodialysis. This affected one (Resident #46) of one resident reviewed for dialysis. The facility identified two residents receiving dialysis.

Inspectors wroteBased on record review, interview and review of policy the facility failed to ensure the influenza vaccine was offered to Resident #8. This affected one (Resident #8) of five residents reviewed for vaccines.

Inspectors wroteBased on observation of posted staffing information and interview the facility failed to ensure current staffing information was posted. This had the potential to affect all 95 residents currently residing in the facility. The facility census was 95.