Health inspection·July 22, 2025

F 0760 Level of Harm - Actual harm Residents Affected - Few Supervisor. Resident 1 said he sat in the lounge for a while on the first floor thinking about how to handle the situation. At approximately 11:00 AM Employee 2 approached him and ask him if he was feeling OK, and also told him he didn't look well, you look white as a sheet. Resident 1 said he was feeling OK at that point but explained to Employee 2 that he was sure he received his roommate's medications. Resident added, the nurse began to monitor me, I remember feeling very tired, and later they sent me to the hospital. Review of the clinical record revealed Employee 2 notified Employee 3 (Registered Nurse) to assess Resident 1. Employee 3 initiated monitoring of Resident 1, which included taking his blood pressure every 15 minutes. A review of Resident 1's clinical record revealed that Resident 1's normal blood pressures were Systolic range 108-135 and diastolic range 52-70. Resident 1's normal heart rate range per his clinical record was 64-71. The physician was notified on July 4, 2025, at 10:45 AM and informed that Resident 1 stated he was given the wrong medication. The physician advised to monitor the Resident and notify him with any changes.On July 4, 2025, at 11:58 AM, Resident 1's BP [blood pressure] was 86/50; at 12:07 PM BP was 77/40; and at 12:07 PM, BP was 77/32. Resident 1's heart rate at 10:56 AM was 57; at 11:58 AM was 57; at 12:07 PM was 44, and at 12:17 was 34. The physician was notified of the drop in blood pressure and low heart rate. The physician ordered Resident 1 to be sent to the hospital. EMS arrived at 12:30 PM. Resident 1 arrived in the ED on July 4, 2025, at 12:44 PM. The facility sent the roommate, Resident 2's medication list with EMS so that the hospital was aware that medications included two AM blood pressure medications (one being a beta blocker that lowers heart rate, reduces blood pressure, and relaxes blood vessels). Review of the hospital discharge summary revealed Resident 1 presented with a medication error resulting in hypotension (low blood pressure). One liter of fluids was administered intravenously (IV) with improvement observed in blood pressure. Resident 1 remained bradycardic (low heart rate) but gradually improved over the course of ED observation. An ECG (electrocardiogram) revealed sinus bradycardia. Resident 1 was maintained on telemetry (remote collection and transmission of data i.e. vital signs) throughout the 5- and 1/2-hour hospital stay. The hospital clinical impression was documented to be accidental overdose. Resident 1 was instructed by hospital staff not to take any meds the rest of the day and to confirm his medications every morning with the nurse as he is being given them.A written statement by Employee 1 stated that Resident 1 believed he was given the wrong medication, but Employee 1 did not admit to a medication error. Employee 1 was questioned by the Nursing Home Administrator (NHA) about identification of the Resident prior to administering medications. Employee 1 stated she recognized the Resident because he used to be on the first floor. A review of Resident 1's record and Resident 2's record revealed both residents were previously on the 1st floor and were moved to the 2nd floor, in the same room, within 24 hours of each other. The facility implemented a plan of correction that included the following: Resident 1 was assessed immediately by RN. Vitals stable at the time. When change in condition was noted, he was transferred to hospital. Resident 2 (Resident 1's Roommate) was also interviewed and assessed at the time of the concern. Every shift vital sign and alert charting being completed on both Residents for three days. Residents were reviewed on that floor to ensure no others received the wrong medication. No complaints noted. Facility completed education with the licensed nurse on medication administration policy at the time of the incident. Resident 1 also received education to ensure his meds are correct prior to taking them. Facility initiated education on medication administration to all licensed staff to ensure appropriate 6 rights of administration are followed, and medication administration policy is followed. Director of Nursing/designee completed observation of medication pass on 2 staff daily x 2 days, then 3 observations per week for 4 weeks to ensure medication administration policy is followed; completed 7/5/2025 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395016 If continuation sheet Page 2 of 3 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 07/22/2025 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 0760 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 7/6/2025, respectively. Then initiated 3 x week for 4 weeks to ensure medication administration policy is followed. Results were reviewed at QAPI (Quality Assurance Performance Improvement) Committee meeting to ensure compliance and quality of care on July 7, 2025. During a phone interview on July 2, 2025, at 10:25 AM, Employee 4 (Licensed Practical Nurse) verified that she had received education on Administering Medications and was able to verbalize understanding, and stated the 6 rights of medication administration, adding the use of 2 forms to identify to ensure she has the right resident.During a phone interview on July 2, 2025, at 10:20 AM, Employee 2 (Licensed Practical Nurse) verified that she had received education on Administering Medications and was able to verbalize understanding, and stated the 6 rights of medication administration, adding the use of 2 forms to identify to ensure she has the right resident.During a phone interview on July 2, 2025, at 10:30 AM Employee 5 (Licensed Practical Nurse) verified that she had received education on Administering Medications and was able to verbalize understanding, and stated the 6 rights of medication administration, adding the use of 2 forms to identify to ensure she has the right resident. The facility demonstrated compliance with the above since July 7, 2025. Information was verified via review of Plan of Correction documentation and staff interviews. During an interview on July 21, 2025, at 1:15 PM, with the NHA and review of the facility's immediate actions, education, and review of the QAPI monitoring process, it was verified that the facility had implemented a plan of correction and achieved compliance ensuring residents are provided adequate safety during medication administration.During an interview on July 22, 2025, at 1:30 PM, the NHA confirmed the facility failed to ensure that residents were free from any significant medication errors for one of two residents, which resulted in harm for Resident 1. 28 Pa Code: 201.18 (b)(1)(3) Management28 Pa Code: 211.10 (d) Resident care policies Event ID: Facility ID: 395016 If continuation sheet Page 3 of 3