Pennsylvania Department of Health
 HANOVER HALL FOR NURSING AND REHABILITATION
Building Inspection Results

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HANOVER HALL FOR NURSING AND REHABILITATION
Inspection Results For:

There are  44 surveys for this facility. Please select a date to view the survey results.

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HANOVER HALL FOR NURSING AND REHABILITATION - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000
Based on an Emergency Preparedness Survey completed on January 30, 2026, at Hanover Hall for Nursing and Rehabilitation, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.
 Plan of Correction:


Initial comments:Name: 'A' BLDG - Component: 01 - Tag: 0000
Facility ID #590102Component 01"A" BuildingBased on a Medicare/Medicaid Recertification Survey completed on January 30, 2026, it was determined that Hanover Hall for Nursing and Rehabilitation had deficiencies that have the potential for minimal harm as related to the following requirements of the Life Safety Code for an existing health care occupancy.  Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).This is a two-story, Type V (111), protected wood frame structure, which is fully sprinklered.
 Plan of Correction:


NFPA 101 STANDARD Number of Exits - Story and Compartment:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
Number of Exits - Story and Compartment
Not less than two exits, remote from each other, and accessible from every part of every story are provided for each story. Each smoke compartment shall likewise be provided with two distinct egress paths to exits that do not require the entry into the same adjacent smoke compartment.
18.2.4.1-18.2.4.4, 19.2.4.1-19.2.4.4
Observations:
Name: 'A' BLDG - Component: 01 - Tag: 0241 Based on observation and interview, it was determined the facility failed to provide two exits, remote from each other, on each floor of the component, affecting one of two floors within the component. Findings include: 1. Observation on January 30, 2026, at 12:00 PM, revealed the 2nd floor lacked two remote exits. Interview with the Facility Representative on January 30, 2026, at 12:00 PM, confirmed the 2nd floor did not have two remote exits.
 Plan of Correction - To be completed: 03/17/2026

1. The facility requests and FSES be conducted by DSI
Initial comments:Name: B,C,D BLDG - Component: 02 - Tag: 0000
Facility ID #590102Component 02Main Building-B, C, D WingsBased on a Medicare/Medicaid Recertification Survey completed on January 30, 2026, it was determined that Hanover Hall for Nursing and Rehabilitation was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.  Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).This is a two-story, Type II (000), unprotected noncombustible structure, with a basement, which is fully sprinklered.
 Plan of Correction:


NFPA 101 STANDARD Multiple Occupancies:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623
Observations:
Name: B,C,D BLDG - Component: 02 - Tag: 0131 Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of building separating common walls, affecting one of seven smoke compartments within the component. Findings include: 1. Observation on January 30, 2026, at 12:20 PM, revealed the 2nd floor door, to Component 01, lacked positive latching hardware, and was secured exclusively by means of an electronic magnet. Interview with the Facility Representative on January 30, 2026, at 12:20 PM, confirmed the fire door lacked positive latching hardware.
 Plan of Correction - To be completed: 03/17/2026

1. B2 door was repaired to positively latch.
2. An Audit of the facility doors will be completed to ensure they positively latch.
3. Maintenance Director will audit 8 doors weekly x4 weeks, then 10 monthly x2 months to ensure positive latch. Audits will be reviewed at QAPI to ensure compliance.

NFPA 101 STANDARD Means of Egress - General:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: B,C,D BLDG - Component: 02 - Tag: 0211 Based on observation and interview, it was determined the facility failed to maintain unobstructed access to the means of egress, affecting one of seven smoke compartments within the component. Findings include: 1. Observation on January 30, 2026, at 12:25 PM, revealed a snowbank obstructing the means of egress, between the Back Stairwell "B2" exit door and the Public Way. Interview with the Facility Representative on January 30, 2026, at 12:25 PM, confirmed the means of egress was obstructed by a snowbank.
 Plan of Correction - To be completed: 03/17/2026

1. Snow was removed from the exit door.
2. An audit of all exit doors was completed to ensure doors are free from obstruction
3. Education will be provided to maintenance technicians to ensure all exits are always unobstructed, including during snowstorms
4. Maintenance Director will complete an audit of all exit doors weekly 8 weeks to ensure they are unobstructed. Audits will be reviewed at QAPI to ensure compliance.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: B,C,D BLDG - Component: 02 - Tag: 0225 Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of exit stairtower enclosures, affecting two of seven smoke compartments within the component. Findings include: 1. Observation on January 30, 2026, at 12:35 PM, revealed the door to the 2nd floor corner stairtower, by Resident Room 220, failed to positively latch within the door frame. Interview with the Facility Representative on January 30, 2026, at 12:35 PM, confirmed the stairtower door did not latch within the frame. 2. Observation on January 30, 2026, at 1:49 PM, revealed the door to the 2nd floor stairtower, by the "C2" Lounge, failed to positively latch within the door frame. Interview with the Facility Representative on January 30, 2026, at 1:49 PM, confirmed the stairtower door did not latch within the frame.
 Plan of Correction - To be completed: 03/17/2026

1. Panic bars have been ordered to replace current bars, to ensure positive latch
2. An Audit of the facility doors will be completed to ensure they positively latch.
3. Maintenance Director will audit 8 doors weekly x4 weeks, then 10 monthly x2 months to ensure positive latch. Audits will be reviewed at QAPI to ensure compliance. Audits will be reviewed at QAPI to ensure compliance.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: B,C,D BLDG - Component: 02 - Tag: 0353 Based on observation and interview, it was determined the facility failed to maintain a supply of spare sprinkler heads, affecting the entire component. Findings include: 1. Observation on January 30, 2026, at 12:47 PM, revealed the facility lacked a supply of spare quick response sidewall sprinkler heads. These heads were evidenced to be in use protecting various areas within the component. Interview with the Facility Representative on January 30, 2026, at 12:47 PM, confirmed the lack of a supply of spare quick response sidewall orientated sprinkler heads.
 Plan of Correction - To be completed: 03/17/2026

1. Facility has ordered additional sprinkler heads to keep in inventory
2. An audit will be completed to ensure all types of sprinkler heads are available
3. Maintenance Director will audit stock of sprinkler replacement heads to ensure all are available. Audits will be reviewed at QAPI to ensure compliance.

NFPA 101 STANDARD Corridor - Doors:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.
Observations:
Name: B,C,D BLDG - Component: 02 - Tag: 0363 Based on observation and interview, it was determined the facility failed to maintain the unobstructed closing of corridor doors, affecting one of seven smoke compartments within the component. Findings include: 1. Observation on January 30, 2026, at 1:22 PM, revealed a wheelchair obstructing the closing of the door, to 1st floor Resident Room SC-2. Interview with the Facility Representative on January 30, 2026, at 1:22 PM, confirmed the corridor door was obstructed from closing.
 Plan of Correction - To be completed: 03/17/2026

1. Wheelchair was removed to ensure door closed.
2. Audit will be completed to ensure there are no obstructions to doors
3. Education will be provided to staff to ensure doors are not obstructed and able to close
4. Maintenance Director will complete audits of doors 3x/week x 4 weeks, then 5 monthly x2 months to ensure no obstruction. Audits will be reviewed at QAPI to ensure compliance.


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