Health inspection·March 14, 2024

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some last day of the assessment period) of December 26, 2023, revealed under Section A - Identification Information subsection A2105. Discharge Status Resident 107 was coded as being discharged to a Short-Term General Hospital. During an interview with Employee 5 (Nurse Assessment Coordinator) on March 14, 2024, at 12:26 PM, she revealed Resident 107 discharged home and not to a hospital, and her assessment was coded inaccurately. During an interview with the NHA on March 14, 2024, at 1:02 PM, she revealed she would expect resident 107's Discharge Return Not Anticipated MDS with ARD of December 26, 2023, to be coded accurately. Review of Resident 358's clinical record on March 12, 2024, at 12:33 PM, revealed diagnoses that included neuroleptic induced parkinsonism (condition caused by use of antipsychotic medication that causes slowed movements, stiffness, and tremors) and dysphagia (difficulty swallowing). Review of Resident 358's physician orders revealed Resident 358 was admitted to hospice services November 13, 2023. Review of Resident 358's significant change MDS dated [DATE], section O0110 special treatments, procedures, and programs, subsection K1 hospice, revealed the facility failed to indicate that Resident 358 was receiving hospice services while a Resident. During an interview with the NHA on March 13, 2024, at 9:50 AM, it was revealed Resident 358's significant change MDS assessment was incorrect, and that corrections had been completed. The NHA stated it is the facility's expectation that MDS assessments would be completed accurately. 28 Pa. Code 211.12(d)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395016 If continuation sheet Page 2 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanover Hall for Nursing and Rehabilitation 267 Frederick Street Hanover, PA 17331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and staff interviews, it was determined the facility failed to develop and implement a comprehensive person-centered care plan to attain or maintain the highest practicable level of physical and mental well-being for one of 25 residents reviewed (Resident 49). Findings include: Review of facility policy, titled Care Plans, Comprehensive Person-Centered, last revised September 2022, read, in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial, and functional needs, is developed and implemented for each resident. The services provided or arranged by the facility, as per the comprehensive care plan, must be culturally-competent and trauma-informed .Trauma-informed Care is an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact, and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures, and practices to avoid re-traumatization. Review of Resident 49's clinical record revealed diagnoses that included Post-Traumatic Stress Disorder (PTSD - a mental and behavioral disorder that develops from experiencing a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life or well-being) and Type 2 Diabetes Mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Resident 49's clinical record revealed a Nurse Practitioner Note on February 22, 2023, that stated Resident is a veteran of the [NAME] Corps and served in the Vietnam War. 2 Purple hearts and a bronze star. Review of Resident 49's care plan revealed a focus area of Richard has a mood problem related to history of PTSD and self-reported signs and symptoms of depression: history of feeling down/depressed, like a failure and has thoughts he would be better off dead (no plan to harm self), initiated August 13, 2020, and last revised December 6, 2022. The care plan failed to reveal what caused his PTSD or triggers related to PTSD. During an interview with Employee 4 (Director of Social Services) on March 12, 2024, at 2:33 PM, the surveyor inquired about Resident 49's diagnosis of PTSD. Employee 4 stated that Resident 49 has PTSD due to being a Vietnam Veteran, he has interventions in place for this, including that he follows with geri-psychiatric for talk therapy, and he goes out of the facility to the VFW (Veterans of Foreign Wars - war veterans service organization) to meet with other veterans and attend events such as flag burning ceremonies. Employee 4 further stated he used to sleep in a recliner, but stopped due sliding out of the recliner when he was having night terrors and flashbacks. She stated that those have gotten much better since he has been receiving geri-psychiatric services. Further review of Resident 49's care plan on March 12, 2024, failed to reveal his interventions of going out to the VFW, or him experiencing night terrors and flashbacks. Review of Resident 49's care plan on March 13, 2024, at 1:00 PM, revealed his focus area of his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395016 If continuation sheet Page 3 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanover Hall for Nursing and Rehabilitation 267 Frederick Street Hanover, PA 17331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some PTSD had been updated to state history of PTSD (Vietnam Vet) with interventions for be sure to approach from the front, calling out name, initiated on March 13, 2024, and does go out to VFW with friends on a regular basis, initiated on March 13, 2024. Further review of Resident 49's care plan on March 13, 2024, at 1:00 PM, revealed his activities care plan was updated to state He is a Vietnam Veteran with PTSD with interventions for Friends occasionally take him to the VFW with them, initiated on March 13, 2024, and monitor/record/report any changes in feeling down or behavior or depression (PTSD- Vietnam Veteran). An interview with the Nursing Home Administrator on March 13, 2024 at 1:32 PM, revealed she would expect Resident 49's care plan to be comprehensive to include the source of his PTSD as well as his triggers and interventions. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395016 If continuation sheet Page 4 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanover Hall for Nursing and Rehabilitation 267 Frederick Street Hanover, PA 17331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure each resident received proper treatment to maintain vision for one of 25 residents reviewed (Resident 90). Residents Affected - Some Findings include: Review of Resident 90's clinical record revealed diagnoses that included adult failure to thrive (syndrome of weight loss, decreased appetite, depressive symptoms, and impaired immune function), hemiplegia (paralysis of one side of the body) following stroke effecting left dominant side, diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), chronic kidney disease (CKD - the kidneys don't function as they should), and depressed mood. During an interview with Resident 90 on March 11, 2024, at 11:31 AM, it was revealed that he hasn't seen an eye doctor to get shots in his right eye for at least two months and that, according to the facility, this was due to the eye doctor not accepting his insurance. He also revealed that he is almost blind in his left eye. Review of Resident 90's physician orders revealed orders for Resident 90 to have routine ophthalmic consult and treatment as needed, effective March 1, 2024. Review of Resident 90's clinical record revealed that he was seen by a retinal specialist on August 25, 2023, and the next appointment was scheduled for November 10, 2023, at 10:30 AM. Review of progress note dated November 10, 2023, revealed that Resident 90 returned to the facility at 11:30 AM, but was not see by the retinal specialist due to them not accepting his new medical insurance. Progress notes dated November 11, 2023, documented Resident 90 was complaining of blurred vision in his right eye, and not being able to see out of his left eye. Resident was transferred to the hospital for evaluation due to history of stroke. Hospital discharge instructions dated November 12, 2023, read, in part, Resident presents to the emergency department for evaluation of left-sided vision loss. Resident also reported that the vision in his right eye is blurry. Resident 90 had a normal neurological exam and was evaluated multiple times over the past 6 months for acute stroke; stroke noted April 2023. Resident had minimally reactive left pupil and reports still can't see out of that eye, right pupil is normal with normal pupillary reflex. Recommendations included it is imperative for resident to follow up with your ophthalmologist upon discharge from the emergency department. Review of email communication between Employee 4 (Social Services Director) and the scheduling coordinator for in-house optometry services revealed on December 10, 2023, it was requested for Resident 90 to be seen for a vision evaluation the next time they are scheduled to be onsite which was to be January 15, 2024. On January 10, 2024, Employee 4 canceled Resident 90's vision appointment with the in-house optometry service due to Resident 90's vision requiring an evaluation at a doctor's office. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395016 If continuation sheet Page 5 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanover Hall for Nursing and Rehabilitation 267 Frederick Street Hanover, PA 17331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0685 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Further review of Resident 90's clinical record revealed a consult report from an out-of-facility optometrist, dated February 8, 2024, for routine eye care and evaluation. Recommendations were made for Resident 90 to follow-up with a retinal specialist as soon as possible, and to follow-up with an out-of-facility doctor for ongoing treatment for glaucoma. A progress note dated February 9, 2024, documented that an appointment was scheduled with a retinal specialist for March 1, 2024, at 1:45 PM. A progress note dated February 12, 2024, documented that an appointment was scheduled with an out-of-facility doctor for glaucoma treatment. During an interview with the Nursing Home administrator on March 13, 2024, at 2:00 PM, it was revealed that the facility had made two appointments at different ophthalmology offices for Resident 90 to seen, and the resident was transported to both offices only to find out they didn't take his new insurance. When asked if the facility should've checked to see if the ophthalmology offices accepted the resident's insurance, it was revealed that the facility forwards that information at the time the appointment is made and, therefore, would expect the office to inform the facility if they don't accept the resident's insurance. It was revealed that the facility had asked the ophthalmologist's office to bill the facility; however, they wanted payment at time of service. It was revealed that the facility could provide payment at time of service if they are aware of that ahead of time. The facility failed to effectively managing routine eye appointments/treatments for Resident 90, resulting in a delay in required vision services and treatments from November 2023 through March 2024. 28 Pa. code 211.12(d)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395016 If continuation sheet Page 6 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanover Hall for Nursing and Rehabilitation 267 Frederick Street Hanover, PA 17331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, observations, record review, and staff interviews, it was determined that the facility failed to provide respiratory care consistent with professional standards of practice for one of 25 residents reviewed (Resident 49). Residents Affected - Few Findings include: Review of facility policy, titled Equipment Management, last revised February 27, 2019, read, in part, All equipment must be wiped down between patient use with a disinfectant cleaning solution/wipe that is rated: bactericidal, fungicidal, virucidal, tuberculocidal or as per manufacturer instructions .CPAP Machine filters: Non disposable filters should be washed monthly. Disposable filters should be changed out monthly .Humidifier chambers: Recommend to use distilled water only. Water should be changed daily. Review of Resident 49's clinical record revealed diagnoses that included Obstructive Sleep Apnea (a common disorder that causes repeated breathing interruptions during sleep), Post-Traumatic Stress Disorder (PTSD - a mental and behavioral disorder that develops from experiencing a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life or well-being), and Type 2 Diabetes Mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Resident 49's physician orders revealed an order for AutoCpap 10 min, 20 max every evening and night shift, with a start date of August 27, 2022. Further review of Resident 49's physician orders on March 12, 2024, failed to reveal orders for cleaning his mask or changing the filter or humidifier water. Observation in Resident 49's room on March 12, 2024, at 10:55 AM, revealed his CPAP mask was laying out on his bedside table. Observation in Resident 49's room on March 13, 2024, at 9:45 AM, revealed his CPAP mask was laying out on his bedside table. During an interview with the Director of Nursing (DON) on March 13, 2024, at 1:33 PM, the surveyor inquired what the facility's process is for managing residents' CPAP. The DON revealed the Resident should have orders for cleaning the mask every morning, that they have bags for sanitary storage of equipment, and he should also have orders for changing the filter and humidifier water. A follow-up interview with the DON on March 14, 2024, at 10:07 AM, revealed Resident 49 now has orders for cleaning his mask and changing the filter and humidifier water, and she would have expected those to be in place. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395016 If continuation sheet Page 7 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanover Hall for Nursing and Rehabilitation 267 Frederick Street Hanover, PA 17331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on facility policy review, clinical record review, and staff interviews, it was determined the facility failed to ensure the monthly pharmacy medication regimen review recommendations were acted upon in a timely manner for two of 25 residents reviewed (Residents 37 and 49). Findings include: Review of facility policy, titled Medication Monitoring and Management, not dated, read, in part The consultant pharmacist reviews written record to determine that: 'Stop order' policies, where utilized, are observed .'Standing orders,' where utilized, are implemented appropriately. Review of Resident 37's clinical record revealed diagnoses that included pain in left knee, hypertension (high blood pressure), and osteoarthritis (a type of arthritis that affects the joints in your body). Review of Resident 37's monthly pharmacy medication regimen review recommendations revealed a recommendation from July 9, 2023, that stated Please add 'Do not exceed 3 grams in 24 hours from all sources' to the PRN [PRN- as needed] Acetaminophen order(s). Thank you. Review of Resident 37's monthly pharmacy medication regimen review recommendations revealed a recommendation from August 11, 2023, that stated Please add a specific temperature to the PRN Acetaminophen order. It should state a specific numerical level, not simply for fever/elevated temperature. Thank you. Review of Resident 37's physician orders revealed an order for Tylenol Extra Strength Oral Tablet (Acetaminophen) Give 1000 mg by mouth at bedtime for chronic pain, with a start date of June 26, 2023. The order failed to reflect the July 2023 pharmacy recommendation. Further review of Resident 37's physician orders revealed an order for Tylenol Oral Tablet (Acetaminophen) Give 650 mg by mouth every 6 hours as needed for elevated temp or mild pain may give suppository if unable to take orally, with a start date of June 26, 2023. The order failed to reflect the July 2023 and August 2023 pharmacy recommendations. An interview with the Director of Nursing (DON) on March 14, 2024, at 1:18 PM, revealed the pharmacy recommendations should have gone to nursing to get the orders updated, and the recommendations should be looked at and responded to timely. Review of Resident 49's clinical record revealed diagnoses that included Post-Traumatic Stress Disorder (PTSD - a mental and behavioral disorder that develops from experiencing a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life or well-being) and diabetes mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Resident 49's monthly pharmacy medication regimen review recommendations revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395016 If continuation sheet Page 8 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanover Hall for Nursing and Rehabilitation 267 Frederick Street Hanover, PA 17331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some pharmacy recommendations from July 9, 2023, that stated Please add 'Do not exceed 3 grams in 24 hours from all sources' to the PRN Acetaminophen order(s). Thank you . Please add a specific temperature to the PRN Acetaminophen order. It should state a specific numerical level, not simply for fever/elevated temperature. Thank you. Review of Resident 49's physician orders revealed an order for Tylenol Tablet (Acetaminophen) Give 650 mg by mouth every 6 hours as needed for fever, with a start date of August 26, 2022. The order failed to reflect the July 2023 pharmacy recommendations. Further review of Resident 49's physician orders revealed an order for Tylenol Tablet (Acetaminophen) Give 650 mg by mouth every 6 hours as needed for pain, with a start date of August 26, 2022. The order failed to reflect the July 2023 pharmacy recommendations. Review of Resident 49's monthly pharmacy medication regimen recommendations revealed a recommendation from November 4, 2023, that stated The resident has orders for Triamcinolone Compound. Please add a stop/reassess date, as topical corticosteroids are not intended for ongoing therapy. Thank you. Further review of Resident 49's monthly pharmacy medication regimen review recommendation from November 4, 2023, revealed it was signed by a nurse practitioner on January 31, 2024, with a notation of agreement and D/c [discontinue] Triamcinolone. Review of Resident 49's progress notes revealed a note on February 1, 2024, that stated [Employee 7] CRNP [Certified Registered Nurse Practitioner], agrees with consultant pharmacy recommendations to D/C Triamcinolone. Review of Resident 49's active physician orders revealed an order for 4:1 Cream (Zinc Oxide 20%oint.//Nystatin 1000U/gm//Triamcinolone 0.1 %//Lidocaine 3%) 60/30/30/30 GM, Apply to affected areas topically every day and evening shift for yeast; rash, with a start date of April 4, 2023. Review of Resident 49's monthly pharmacy medication regimen review recommendations revealed a recommendation from December 4, 2023, Please include the level of pain at which the PRN Tramadol is to be administered. Thank you. Review of Resident 49's physician orders revealed an order for Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) give 50 mg, with a start date of March 8, 2023, and an end date of March 4, 2024. Further review of the order failed to reveal a level of pain at which the medication should be administered. During an interview with the DON on March 14, 2024, at 1:18 PM, she revealed the pharmacy recommendations should have gone to nursing to get the orders updated, and that recommendations should be looked at and responded to timely. During a follow-up interview with the DON on March 14, 2024, at 2:47 PM, she revealed there was a triamcinolone cream that was discontinued on March 4, 2024, but that was due to a wound that had resolved. The triamcinolone compound that was recommended to be discontinued appeared to be the one that was still an active order, with a start date of April 4, 2023. 28 Pa. Code 211.9(k) Pharmacy Services. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395016 If continuation sheet Page 9 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanover Hall for Nursing and Rehabilitation 267 Frederick Street Hanover, PA 17331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395016 If continuation sheet Page 10 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanover Hall for Nursing and Rehabilitation 267 Frederick Street Hanover, PA 17331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. Based on observations, facility policy review, and staff interview, it was determined that the facility failed to ensure controlled substances were contained in a permanently affixed locked compartment for two of two medication rooms observed (A1/B1 hall and C2/D2 hall); failed to ensure adherence to medication expiration dates for one of two medication storage rooms observed (A1/B1 hall); and failed to ensure appropriate labeling of medication when opened for one of two medication storage rooms observed (A1/B1 hall). Findings include: Review of facility policy, titled Medication Storage in the Facility, last reviewed August 24, 2023, stated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Further review of the policy revealed a section titled Procedures subsection I stated, Controlled medications are stored separately from other medications in a locked drawer or compartment designated for that purpose. Subsection M stated, Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal and reordered from the pharmacy, if a current order exists. Review of facility policy, titled Administering Medication, last reviewed August 24, 2023, section titled Policy Interpretation and Implementation, number 8 stated, in part, .When opening a multi-dose container, the date opened shall be recorded on the container. Further review of the policy revealed a section titled Injection Practices and Sharps Safety (Medications and Infusates) stated, Multi-dose vials which have been opened or accessed (e.g. needle-punctured) are dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for the opened vial. Observation of the A1/B1 hall medication room on March 13, 2024, at 9:40 AM, revealed an unlocked medication refrigerator. Further observation of the medication refrigerator revealed one box of lorazepam (a schedule IV-controlled substance) containing a bottle with 30 milliliters (mL - Metric unit of measure) of lorazepam lying on a shelf in the refrigerator; one opened, partially used multi-dose vial of Aplisol (substance that's used to detect exposure to tuberculosis) with no open date documented on the vial; and one opened, partially used multi-dose vial of Energix-B (vaccine for immunization against Hepatitis B virus), with no open dated documented on the vial. Further review of the medication room revealed one house stock tube of Glutose 15 gel (used to treat low blood sugar) with a do not use after date of October 2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395016 If continuation sheet Page 11 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanover Hall for Nursing and Rehabilitation 267 Frederick Street Hanover, PA 17331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Observation of the C2/D2 hall medication room on March 13, 2024, at 11:57 AM, revealed an unlocked medication refrigerator. Further review of the medication refrigerator revealed two boxes of lorazepam (a schedule IV-controlled substance) containing a total of 59 mL of lorazepam lying on a shelf in the refrigerator. Residents Affected - Some During an interview on March 14, 2024, at 11:06 AM, with the Nursing Home Administrator (NHA) and Director of Nursing, after notifying them of the observations made in the medication rooms, the NHA stated it is the expectation of the facility that medication refrigerators are to be locked, multi-dose vials of medications are to be dated when opened, and expired medications are to be disposed of. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12 (d)(2)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395016 If continuation sheet Page 12 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanover Hall for Nursing and Rehabilitation 267 Frederick Street Hanover, PA 17331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. Based on review of select facility documentation, observations, and staff interview, it was determined that the facility failed to follow appropriate portion sizes for residents prescribed double portions for three of five residents observed (Residents 5, 7, and 32); and failed to provide therapeutic diet restrictions (a meal plan that controls the intake of certain foods or nutrients) for five of five residents observed on the carbohydrate controlled diet restriction (Residents 28, 58, 70, 83, and 409) during one of one tray line meal service observed. Findings include: Review of Document titled Carbohydrate Controlled Diet not dated, read, in part, Food Group: Desserts .Foods Allowed: Half portion of regular desserts. Review of the meal extension sheets revealed that residents on the carbohydrate controlled diet restriction should be served half of a 2 x 3 inch square of the chocolate chip brownie bar. Observation of lunch meal tray line service on March 13, 2024, between 11:10 AM and 12:07 PM, revealed Residents 28, 58, 70, 83, and 409's, tray tickets had notation that they were on the carbohydrate controlled diet restriction, and were served a whole square of the chocolate chip brownie bar. Review of Document titled Portion Sizes last revised July 2023, read, in part, Meal Category: Meat (Lunch), Double Portion: 6 oz (2svg-serving) Observation of lunch meal tray line service on March 13, 2024, between 11:10 AM and 12:07 PM, revealed Residents 5, 7, and 32's, tray tickets had notation that they should be provided double protein portions, and were served a single breaded chicken sandwich with one patty. Observation on the units on March 13, 2024, between 11:59 AM and 12:37 PM, confirmed Residents 5, 7, and 32, were not served double protein portions. During a staff interview on March 14, 2024, at 10:47 AM, the observations of the lunch meal tray line service from March 13, 2024, were discussed with the Nursing Home Administrator (NHA). The NHA revealed she would expect therapeutic diets and double protein portions to be followed. 28 Pa. Code 201.14(a) Responsibility of licensee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395016 If continuation sheet Page 13 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanover Hall for Nursing and Rehabilitation 267 Frederick Street Hanover, PA 17331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on completion of a test tray and resident and staff interviews, it was determined that the facility failed to provide foods that were at an appetizing temperature for one of one meals tested. Residents Affected - Few Findings include: An interview with Resident 408 on March 11, 2024, at 11:17 AM, revealed his food is not always served hot during meals. During the resident group interview completed on March 12, 2024, at 10:00 AM, multiple residents voiced concerns with the temperature of the food served during meal service. During an interview with Employee 3 on March 13, 2024, at 12:20 PM, he revealed that he conducts test trays monthly, and hot foods should be served at or above 135 degrees and chilled foods should be served at or below 40 degrees. A test tray was completed on March 13, 2024, at 12:26 PM, utilizing a lunch tray served from tray line in the main kitchen. A test tray was served and placed in a closed food cart for approximately two minutes prior to being delivered to the C1 unit (other trays for room service were being delivered here also at this time). The test tray included: a breaded chicken sandwich, chilled diced pears, a chocolate chip brownie bar, apple juice, and coffee. Temperatures taken by Employee 3 revealed the breaded chicken sandwich was 129 degrees and the chilled pears were 70 degrees, not palatable. An interview with the Nursing Home Administrator on March 13, 2024, at 1:45 PM, revealed she would expect food and beverages to be served at palatable temperatures. 28 Pa. Code 201.14(a) Responsibility of licensee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395016 If continuation sheet Page 14 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanover Hall for Nursing and Rehabilitation 267 Frederick Street Hanover, PA 17331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food and beverages in accordance with professional standards for food service safety in the main kitchen and four of four nourishment areas. Findings include: Review of facility policy, titled Policy: Storage Areas, not dated, read, in part, Food should be dated as it is placed on the shelves. Date marking to indicate the date or day by which are ready to eat .Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded .All foods should be covered, labeled, and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable) or discarded. Review of facility policy, titled Policy: Food from outside Sources, last revised July 2023, revealed, Visitors/family members will label food and beverages with the resident's name, room number, and date .Perishable foods with a 'use by' date which is 3 days from the date that it was brought into the facility. Observation in the main kitchen on March 11, 2024, at 10:07 AM, revealed a bag of hot dog buns, open and not dated; a bag of white bread open and not dated; and three bags of white bread not dated. Observation of the reach-in refrigerator on March 11, 2024, at 10:11 AM, revealed: one pan of bologna dated 2-29; one container of turkey salad dated 3-7; one bag of cheddar cheese not dated and left open to air; one case of hot dogs left open to air; one pan of melted margarine left open to air; three halves of tomatoes wrapped in plastic wrap not dated; one pan of gravy labeled 2-29; one carton of breakfast eggs open and dated 2-18; one pan of ground meat labeled 3-1; one pan of baked beans labeled 3-5; one whole tomato not dated; one boiled egg not dated; and a half of an onion wrapped in plastic wrap, not dated. An interview with Employee 3 (Dietary Manager) on March 11, 2024, at 10:12 AM, revealed all aforementioned items in the reach-in refrigerator should be thrown away, food items should be sealed properly and not left open to air, and a dietary staff member should be going through the reach-in refrigerators daily to ensure expired items are discarded. Observation of the walk-in refrigerator on March 11, 2024, at 10:13 AM, revealed two bags of mozzarella cheese labeled best by February 20, 2024. Observation in the main kitchen on March 11, 2024, at 10:14 AM, revealed: one bag of elbow macaroni noodles open and not dated; and one bag of breadcrumbs open and not dated. Observation of the preparation reach-in refrigerator in the main kitchen on March 11, 2024, at 10:17 AM, revealed: a bin containing peanut butter and jelly sandwiches all labeled 3-3; and seven turkey sandwiches all labeled 3-6. An interview with Employee 3 on March 11, 2024, at 10:18 AM, revealed the sandwiches should be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395016 If continuation sheet Page 15 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanover Hall for Nursing and Rehabilitation 267 Frederick Street Hanover, PA 17331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 thrown away. Level of Harm - Minimal harm or potential for actual harm Observation during initial tour of the C1 Pantry Area on March 11, 2024, at 10:28 AM, revealed: two packages of fudge round cookies and two packages of oatmeal cookies, not dated. Residents Affected - Some Observation of the refrigerator in the C1 Pantry Area on March 11, 2024, at 10:29 AM, revealed: one shelf of nutritional juice drinks not dated with a thawed date; four nutritional shakes not dated with a thawed date; one tray of nutritional juice drinks not dated with a thawed date; and one container of thickened cranberry juice open and not dated. An interview with Employee 3 on March 11, 2024, at 10:31 AM, revealed nutritional supplements that come in frozen should be labeled with a thawed date so staff knows the expiration date of two weeks after the thawed date, and open juices should be labeled with an open date and discarded after seven days. Observation during initial tour of the B1 Pantry Area on March 11, 2024, at 10:33 AM, revealed: one package of fudge round cookies and one package of oatmeal cookies not dated; and a bin of individual butter packets stored at room temperature with directions to be kept refrigerated. Observation of the refrigerator in the B1 Pantry Area on March 11, 2024, at 10:34 AM, revealed: one jar of pasta sauce from an outside source, open, and not labeled with a resident's name, room number, or date; one container of Italian dressing from an outside source, open, and not labeled with a resident's name, room number, or date; one bag of prepared chicken labeled with a resident's name and date of 3-3; one plastic bag containing food wrapped in foil from an outside source, not labeled with a resident's name, room number, or date; and one drawer of nutritional juice drinks not labeled with a thawed date. An interview with Employee 3 on March 11, 2024, at 10:36 AM, revealed it is the facility's process that perishable foods from outside sources are labeled with a resident's room number, name, and date, and discarded after three days. Observation during initial tour of the B2 Pantry Area on March 11, 2024, at 10:41 AM, revealed one bin of individually wrapped cookies, not dated. Observation of the refrigerator in the B2 Pantry Area on March 11, 2024, at 10:43 AM, revealed: one bin of nutritional juice drinks not labeled with a thawed date; one bag containing two packages of meat labeled John not labeled with resident's room number or date; one plastic storage container of salad dressing labeled Shirley 2-7 without a room number; and one bin of assorted individual condiments, not dated. Observation during initial tour of the C2 Pantry Area on March 11, 2024, at 10:47 AM, revealed: two packages of fudge round cookies and two packages of oatmeal cookies not dated. Observation of the refrigerator in the C2 Pantry Area on March 11, 2024, at 10:48 AM, revealed: one bag containing a rotten banana and another unidentified wrapped food item not labeled with a resident's room number, name, or date. Observation of the freezer in the C2 Pantry Area on March 11, 2024, at 10:49 AM, revealed two grocery bags full of individual popsicles from an outside source, not labeled with a resident's room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395016 If continuation sheet Page 16 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanover Hall for Nursing and Rehabilitation 267 Frederick Street Hanover, PA 17331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 number, name, or date. Level of Harm - Minimal harm or potential for actual harm During an interview with Employee 3 on March 11, 2024, at 10:50 AM, the surveyor revealed the concerns with food and beverage storage in the main kitchen and four pantries. Employee 3 revealed his understanding and said We'll get all that fixed. Residents Affected - Some An interview with the Nursing Home Administrator on March 12, 2024, at 1:36 PM, revealed it is the facility's expectation that expired items are discarded, foods items are labeled and dated per facility policy, and food and beverages are stored and utilized in accordance with professional standards. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 211.6(f) Dietary services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395016 If continuation sheet Page 17 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanover Hall for Nursing and Rehabilitation 267 Frederick Street Hanover, PA 17331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on facility record review, facility policy review, and staff interviews, it was determined that the facility failed to provide education regarding the benefits and risks of the influenza and pneumococcal vaccines for three of five residents reviewed for vaccination status (Residents 61, 90, and 92). Residents Affected - Few Findings include: Review of facility policy, titled Influenza Vaccine, last reviewed August, 2023, revealed the policy statement included, The facility shall provide pertinent information about the significant risks and benefits of vaccines to staff and residents (or residents' legal representatives); for example, risk factors that have been identified for specific age groups or individuals with risk factors such as allergies or pregnancy. Review of subsection 4 of the policy revealed it stated, Prior to the vaccination, the resident (or residents' legal representative) or employee will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. (See current vaccine information statements at [Centers for Disease Control's website] for educational materials.) Provisions of such education shall be documented in the resident's/employee's medical record. Review of subsection 3 of the facility's policy, titled Pneumococcal Vaccine, last reviewed August, 2024, revealed it stated, Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. (See current vaccine information statements at [Centers for Disease Control's website] for educational materials.) Provision of such education shall be documented in the resident's medical record. Review of the facility's infection control's vaccination tracking data revealed that Residents 61, 90, and 92 had refused the 2023/2024 influenza vaccination. Further review revealed Resident 92's Resident Representative had refused the pneumococcal immunization. During a staff interview on March 14, 2024, at approximately 10:40 AM, Employee 2 (Facility Infection Control Nurse) was asked if Residents 61, 90, and 92 were provided education and risks and benefits of the vaccines via the identified Centers for Disease Control education material. Employee 2 stated that the Residents/Resident Representatives were not provided with the educational material at the time of refusal. During a staff interview on March 14, 2024, at approximately 1:00 PM, Nursing Home Administrator revealed it was the facility's expectation that Residents/Resident Representatives would be provided the Centers for Disease Control's educational information sheet on the influenza and pneumococcal vaccinations at the time of refusal of the vaccine. 28 Pa code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395016 If continuation sheet Page 18 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanover Hall for Nursing and Rehabilitation 267 Frederick Street Hanover, PA 17331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0942 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Based on review of facility documentation, and interviews it was determined that the facility failed to ensure that direct care nursing staff completed training/demonstrated competency upon hire and annually thereafter related to resident rights for two of five direct care staff members reviewed (Employees 8 and 9). Findings include: Review of the annual Staff Education Reports for five direct care staff members revealed that Employees 8 and 9 (Nurse Aides) failed to complete annual training for resident rights in the past year. During an interview with the Nursing Home Administrator (NHA) on March 14, 2024, at 10:55 AM it was revealed that the facility scheduled in-person training lasting one hour in duration each month and covered a different topic. It was further revealed that all staff were expected to attend one of the two training sessions offered each month. The NHA acknowledged that at times a staff member doesn't attend the required monthly training, and the facility doesn't provide make-up sessions. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.20(a)(d) Staff development. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395016 If continuation sheet Page 19 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hanover Hall for Nursing and Rehabilitation 267 Frederick Street Hanover, PA 17331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on review of nurse aide in-service records and staff interview, it was determined that the facility failed to ensure that all nurse aide staff received a minimum of 12 hours of in-service education training each year for five of five direct care staff members reviewed (Employees 8, 9, 10, 11, and 12). Findings include: Review of the facility's yearly mandatory in-service training failed to reveal documented evidence that Employees 8, 9, 10, 11, and 12 (Nurse Aides) met the yearly regulatory minimum training requirements. The following were documented hours of training for each employee: Employee 8 had 7 hours; Employee 9 had 6 hours; Employee 10 had 7 hours; Employee 11 had 7 hours; and Employee 12 had 7 hours. During an interview with the Nursing Home Administrator (NHA) on March 14, 2024, at 10:55 AM, it was revealed that the facility scheduled in-person training lasting one hour in duration each month and covered a different topic. It was further revealed that all staff are expected to attend one of the two training sessions offered each month; no make-up sessions were scheduled. The NHA acknowledged that training scheduled for August 2023 and December 2023 were canceled due to a COVID-19 outbreak, and the training schedule was revamped for the mandatory topics to be covered; however, the two missed hours weren't rescheduled. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 201.19(7) Personnel policies. 28 Pa. Code 201.20(a)(d) Staff development. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395016 If continuation sheet Page 20 of 20