Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hanover Hill Health Care Center during CMS and state inspections, most recent first.
Failure to follow a wound care order for a healed skin tear. A resident’s left forearm skin tear was documented as healed and open to air, yet a dated kerlix dressing remained in place on later observations even though the order had been discontinued. An LPN confirmed the wound was healed and no longer needed a dressing.
A resident was hospitalized due to a significant medication error where they received another resident's Metoprolol 150 mg instead of their prescribed 12.5 mg dose. This resulted in hypotension and a six-day hospital stay.
The facility failed to properly sanitize dishes and maintain hand hygiene in the kitchen. Expired chlorine test strips were used to verify sanitizing solution concentration, and a Dietary Aide did not wash hands between handling dirty and clean dishes, violating FDA Food Code standards.
The facility failed to maintain an effective infection prevention and control program, leading to a GI outbreak affecting 22 residents. The Infection Preventionist did not investigate initial cases or ensure consistent application of contact precautions. Documentation inconsistencies were found in residents' medical records, and policies on outbreak management were not effectively implemented.
A facility failed to conduct an accurate PASARR screening for a resident with PTSD and OCD, leading to a lack of referral to the state-designated authority for evaluation. The initial screening incorrectly indicated no mental illness, which was confirmed by the Director of Social Services.
The facility failed to properly store medications on one medication cart. Two unlabeled medication cups containing medications for two different residents were found on the cart. A Registered Nurse confirmed the lack of labeling, which violated the facility's policy requiring medications to be stored in their original containers.
The facility's assessment failed to include specific staffing needs for each resident unit and shift, such as day, evening, and night. The review of the Facility Assessment and CMS form 671, signed by the Administrator, showed that the assessment did not specify staffing needs for the different units, including a 24-bed Alzheimer's Unit, nor did it adjust staffing based on changes in the resident population. The Daily Nursing Schedule also lacked specific staffing needs by shift, which was confirmed by the Administrator.
Failure to Follow Wound Care Order for Healed Skin Tear
Penalty
Summary
The facility failed to follow a physician’s wound care order for Resident #105’s left forearm skin tear. The order, dated 2/12/26, directed staff to cleanse the wound, pat dry, approximate the wound with a cotton tip applicator, secure with steristrips, cover with a nonadherent telfa pad, wrap with kerlix, and secure the dressing, with hydrogel permitted if additional moisture was needed, to be done every night shift until healed. The order was discontinued on 3/6/26, and review of the March 2026 Treatment Administration Record showed there were no current orders after that date. Progress notes documented that the left forearm skin tear was healed and left open to air on 3/4/26 and again noted as healed and open to air on 3/5/26. Despite this, observations on 3/8/26 and 3/9/26 showed a white kerlix dressing still in place on the left forearm, with grey smudged areas and frayed, uneven edges. The dressing was dated 3/4/26, and an LPN confirmed during interview that the wound was healed, no longer needed a dressing, and that the date on the dressing indicated the day it had been applied.
Medication Error Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, resulting in a serious incident involving a resident. The resident, who had an order for Metoprolol Succinate ER 12.5 mg once a day for hypertension, was mistakenly administered another resident's medication, which included Metoprolol 150 mg. This error led to the resident experiencing dizziness and low blood pressure, necessitating hospitalization. Upon review, it was found that the resident was admitted to the hospital with a diagnosis of hypotension due to a Metoprolol overdose. The hospital discharge summary confirmed that the adverse effects were due to a beta-blocker overdose. The resident required a six-day hospital stay before being discharged back to the facility. The incident was identified and reported to the administration and the nurse practitioner immediately after it occurred.
Improper Dish Sanitization and Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure proper handling and sanitization of dishes in accordance with professional standards for food service safety. During an observation in the main kitchen, it was noted that the facility was using a low temperature dishwasher with chemical sanitization. However, the chlorine test strips used to determine the concentration of the sanitizing solution were expired. This was confirmed by the Food Service Supervisor, who acknowledged that the expired test strips were being used to verify the appropriate concentration of chlorine for dish sanitization. The facility's policy required the use of Ecolab Chlorine Test Paper to test water and record results, but the expired strips compromised the accuracy of these tests. Additionally, an observation of a Dietary Aide in the dishwashing room revealed a failure to perform hand hygiene between handling dirty and clean dishes. The Dietary Aide was seen rinsing food off dirty dishes and then unloading clean dishes without washing hands in between these tasks. This was confirmed in an interview with the Dietary Aide, who admitted to not performing hand hygiene between contact with soiled and clean items. According to the FDA Food Code, food employees are required to wash their hands after handling soiled equipment or utensils, which was not adhered to in this instance.
Inadequate Infection Control and Documentation in GI Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of a proper surveillance system to identify and manage gastrointestinal (GI) infections among residents. The report highlights that 22 residents experienced GI symptoms, such as nausea, vomiting, and diarrhea, without adequate documentation of symptom resolution or outcomes. The Infection Preventionist, Staff I, confirmed that there was no investigation conducted when the initial five residents were identified with GI symptoms, and the on-call provider did not order contact precautions, assuming it was a viral infection. Further review of the facility's acute gastroenteritis line list revealed inconsistencies in the documentation of symptom onset and resolution dates for several residents. For instance, Resident #33's medical record showed episodes of vomiting on different dates than those listed in the line list. Similar discrepancies were found in the records of Residents #93, #11, #44, #21, #41, #2, and #267, indicating a lack of accurate record-keeping and monitoring of the residents' conditions. Additionally, Resident #267 was observed not to be on contact precautions initially, despite having been symptomatic and later placed on precautions. The facility's policies on outbreak investigation and transmission-based precautions were not effectively implemented. The Infection Preventionist relied solely on nurse reports for GI symptoms and did not ensure consistent application of contact precautions or accurate documentation. The facility's failure to adhere to its policies and protocols for managing infectious outbreaks contributed to the spread of GI symptoms among residents, affecting three out of four units within the facility.
Inaccurate PASARR Screening for Resident with Mental Health Disorders
Penalty
Summary
The facility failed to ensure an accurate Preadmission Screening and Resident Review (PASARR) for a resident with mental health disorders. Upon review, it was found that a resident admitted in May 2024 with diagnoses of post-traumatic stress disorder and obsessive-compulsive disorder was not properly identified in the PASARR Level I screening. The screening incorrectly indicated that the resident did not have a mental illness, leading to a failure to refer the resident to the appropriate state-designated authority for evaluation and determination of appropriate placement and services. This oversight was confirmed during an interview with the Director of Social Services.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure proper storage of medications on one of the four medication carts observed. During an observation, two clear plastic medication cups containing medications were found on the First Floor [NAME] cart. One cup was placed on top of the other, and neither cup was labeled with resident identifiers. An interview with Staff E, a Registered Nurse, confirmed that the medication cups were unlabeled and contained medications for two different residents. The facility's policy, revised on 8/1/24, requires that medications and biologicals for each resident be stored in their original containers, which was not adhered to in this instance.
Facility Assessment Lacks Specific Staffing Needs
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included specific staffing needs for each resident unit and for each shift, such as day, evening, and night. This deficiency was identified through a review of the Facility Assessment (FA) and CMS form 671, which was signed by the Administrator. The FA did not specify staffing needs for the different resident units, including a 24-bed Alzheimer's Unit, and did not adjust staffing based on changes in the resident population. Additionally, the facility's Daily Nursing Schedule revealed the presence of a skilled unit, two long-term care units, and the Alzheimer's Unit, but did not reflect specific staffing needs by shift. An interview with the Administrator confirmed these findings.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Joseph Residence | 0.1 mi | ★★★★★ | 10 | 0 |
| Saint Teresa Rehabilitation & Nursing Center | 0.5 mi | ★★★★★ | 7 | 0 |
| Mount Carmel Rehabilitation And Nursing Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Maple Leaf Health Care Center | 1.1 mi | ★★★★★ | 2 | 0 |
| Villa Crest Nursing And Retirement Center | 1.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.