Health inspection·February 3, 2025

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on document review, policy review, and resident and staff interviews, it was determined that the facility failed to ensure sufficient nursing staff to provided nursing and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by individual plans of care for one of four residents reviewed (Resident 4). Findings Include: A review of the facility's policy, titled Care Plans-Comprehensive Person-Centered, revised September 2022, read, in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of the facility's policy, titled Resident Rights, revised October 2022, read, in part, Employees shall treat all residents with kindness, dignity and respect. The policy continued, residents have the right to have the facility respond to his or her grievances. Review of Resident 4's interdisciplinary plan of care revealed a shower scheduled on Tuesday and Friday during 7-3, day shift. A review of the facility's Grievance and Concern Form, dated December 12, 2024, revealed a documented concern initiated by Resident 4's daughter that he was not receiving his scheduled showers. According to documentation, Resident 4's shower days had been on the evening shift but were changed to the day shift and the nursing staff received education. An interview with Resident 4 on February 3, 2025, at 1:35 PM, revealed ongoing concerns with receiving showers and other hygienic cares. A review of Resident 4's bathing documentation x 30 days revealed a bed bath provided on January 7 and 28, 2025. The documentation also revealed no documentation of Resident 4 receiving neither a shower or bed bath on January 17 and 21, 2025. An interview with the Director of Nursing (DON) on February 3, 2025, at 2:15 PM, revealed an interview with the Nurse Aide (Employee 4), revealed she did not provide bathing to Resident 4 on January 17 or 21, 2025, due to being short staffed and unable to provide bathing to Resident 4 as per his person-centered plan of care. Page 1 of 4 395016 395016 02/03/2025 Hanover Hall for Nursing and Rehabilitation 267 Frederick Street Hanover, PA 17331

F 0725 A continued interview with the DON confirmed the facility to be short-staffed on those dates and staff were unable to provide care to Resident 4 per his person-centered plan of care. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18 (b) (1) Management Residents Affected - Few 28 Pa. Code 211.12 (d) (2) (5) Nursing services 395016 Page 2 of 4 395016 02/03/2025 Hanover Hall for Nursing and Rehabilitation 267 Frederick Street Hanover, PA 17331

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on clinical record review, policy and document review, and staff interview, it was determined that the facility failed to implement policies and procedures to ensure that each resident is offered the COVID-19 vaccine, when available, and if the vaccination requires multiple doses, the resident and/or representative has the opportunity to accept or refuse the COVID-19 vaccine for one of four residents reviewed (Resident 2). Findings Include: A review of the facility's policy, titled Coronavirus (COVID-19) and COVID-19 Vaccine Policy, revised on February 18, 2022, read, in part, The vaccine will be offered and administered to residents per the most current Manufacturers', CDC [Centers for Disease Control], Federal, State, and/or local guidance. The policy continued, If a vaccine requires multiple doses, or an additional 3rd dose or more, or booster, educational information and consents will be completed for each dose administered. And Documentation of vaccination for residents: Acceptance or refusal of the vaccine. A review of electronic mail correspondence from the facility's pharmaceuticals provider dated October 4, 2024, read, Hello customers, we are pleased to announce that we have received the 2024-2025 Spikevax, a vaccine indicated for immunization to prevent COVID-19. Also, For individuals previously vaccinated with any COVID-19 vaccine, administer the dose of Spikevax at least 2 months after the last dose of COVID-19. A review of Resident 2's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - a chronic lung condition that causes inflammation and narrowing of the airways, leading to ongoing breathing difficulties) and chronic kidney disease (CKD - long-term condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood). A review of Resident 2's immunization documentation revealed the most recent COVID-19 vaccination was administered on February 29, 2024. A continued review of Resident 2's clinical record revealed no documentation of communication with the Resident and/or his Representative regarding the availability of the 2024-2025 Spikevax. Also, no documentation of Resident 2 receiving the most recent vaccine offered by the facility's pharmacy. Review of Resident 2's progress notes revealed he contracted the COVID-19 infection on December 8, 2024, and passed away on January 2, 2025. An interview with the Director of Nursing on February 3, 2025, at 1:10 PM, revealed the facility had not offered the most recent vaccine to Resident 2 or his Representative and stated, if the facility does not have enough resident or staff interest in the COVID-19 vaccine, the facility does not order it from the pharmacy due to cost and fear of waste of the vial of vaccine. 28 Pa. Code 201.18 (b) (1) Management 395016 Page 3 of 4 395016 02/03/2025 Hanover Hall for Nursing and Rehabilitation 267 Frederick Street Hanover, PA 17331

F 0887 28 Pa. Code 211.12 (d) (2) (5) Nursing services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395016 Page 4 of 4