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Health Inspection Summary
Hanover Health and Rehabilitation Center
8139 Lee Davis Road
Mechanicsville, VA 23111
(804) 559-5030

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Deficiency Category
Inspection Date:
4/28/22
Complaint Reporting Period:
3/1/24 - 2/28/25
Inspection Date:
8/7/19
Complaint Reporting Period:
3/1/23 - 2/29/24
Inspection Date:
3/5/18
Complaint Reporting Period:
3/1/22 - 2/28/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies040
Quality of Life and Care Deficiencies355
Infection Control Deficiencies031
Resident Assessment and Care Planning Deficiencies543
Nursing and Physician Services Deficiencies030
Resident Rights Deficiencies131
Nutrition and Dietary Deficiencies010
Pharmacy Service Deficiencies225
Environmental Deficiencies000
Administration Deficiencies000

Detailed result for inspection on 4/28/22
Date of last standard health inspection:4/28/22Read the full report (PDF)
Date(s) of complaint inspection(s) between 3/1/24 - 2/28/25
No complaint inspections
Date(s) of infection control inspection(s) between 3/1/24 - 2/28/25
No infection control inspections
Total number of Health Deficiencies for this nursing home:11
Average number of Health Deficiencies in Virginia:12.2
Average number of Health Deficiencies in the United States:9.6
Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide routine and 24-hour emergency dental care for each resident.

4/28/226/7/22
2 - Minimal harm or potential for actual harm
Few

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

4/28/226/7/22
2 - Minimal harm or potential for actual harm
Some

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

4/28/226/7/22
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

4/28/226/7/22
2 - Minimal harm or potential for actual harm
Few

Ensure services provided by the nursing facility meet professional standards of quality.

4/28/226/7/22
2 - Minimal harm or potential for actual harm
Some

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

4/28/226/7/22
2 - Minimal harm or potential for actual harm
Few

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

4/28/226/7/22
2 - Minimal harm or potential for actual harm
Some

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

4/28/226/7/22
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

4/28/226/7/22
2 - Minimal harm or potential for actual harm
Some
Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure medication error rates are not 5 percent or greater.

4/28/226/7/22
2 - Minimal harm or potential for actual harm
Few

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.

4/28/226/7/22
2 - Minimal harm or potential for actual harm
Few
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 8/7/19
Date of last standard health inspection:8/7/19Read the full report (PDF)
Date(s) of complaint inspection(s) between 3/1/23 - 2/29/24
No complaint inspections
Date(s) of infection control inspection(s) between 3/1/23 - 2/29/24
Total number of Health Deficiencies for this nursing home:25
Average number of Health Deficiencies in Virginia:11.6
Average number of Health Deficiencies in the United States:9.4
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

8/7/199/21/19
2 - Minimal harm or potential for actual harm
Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

8/7/199/21/19
4 - Immediate jeopardy to resident health or safety
Few

Respond appropriately to all alleged violations.

8/7/199/21/19
2 - Minimal harm or potential for actual harm
Few

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

8/7/199/21/19
2 - Minimal harm or potential for actual harm
Few
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

8/7/199/21/19
4 - Immediate jeopardy to resident health or safety
Few

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

8/7/199/21/19
2 - Minimal harm or potential for actual harm
Few

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

8/7/199/21/19
2 - Minimal harm or potential for actual harm
Few

Provide activities to meet all resident's needs.

8/7/199/21/19
2 - Minimal harm or potential for actual harm
Few

Provide safe and appropriate respiratory care for a resident when needed.

8/7/199/21/19
2 - Minimal harm or potential for actual harm
Some
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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.

6/30/237/20/23
2 - Minimal harm or potential for actual harm
Few

Provide and implement an infection prevention and control program.

8/7/199/21/19
2 - Minimal harm or potential for actual harm
Some

Develop and implement policies and procedures for flu and pneumonia vaccinations.

6/30/237/20/23
2 - Minimal harm or potential for actual harm
Few
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

PASARR screening for Mental disorders or Intellectual Disabilities

8/7/199/21/19
2 - Minimal harm or potential for actual harm
Some

Ensure services provided by the nursing facility meet professional standards of quality.

8/7/199/21/19
4 - Immediate jeopardy to resident health or safety
Few

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

8/7/199/21/19
2 - Minimal harm or potential for actual harm
Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

8/7/199/21/19
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Observe each nurse aide's job performance and give regular training.

8/7/199/21/19
2 - Minimal harm or potential for actual harm
Some

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

8/7/199/21/19
4 - Immediate jeopardy to resident health or safety
Few

Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.

8/7/199/21/19
4 - Immediate jeopardy to resident health or safety
Few
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

8/7/199/21/19
2 - Minimal harm or potential for actual harm
Some

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

8/7/199/21/19
2 - Minimal harm or potential for actual harm
Few

Reasonably accommodate the needs and preferences of each resident.

8/7/199/21/19
2 - Minimal harm or potential for actual harm
Few
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

8/7/199/21/19
2 - Minimal harm or potential for actual harm
Many
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

8/7/1910/24/19
2 - Minimal harm or potential for actual harm
Few

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

8/7/199/21/19
2 - Minimal harm or potential for actual harm
Few
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 3/5/18
Date of last standard health inspection:3/5/18Read the full report (PDF)
Date(s) of complaint inspection(s) between 3/1/22 - 2/28/23
Date(s) of infection control inspection(s) between 3/1/22 - 2/28/23
Total number of Health Deficiencies for this nursing home:15
Average number of Health Deficiencies in Virginia:11.7
Average number of Health Deficiencies in the United States:8.7
Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide safe, appropriate pain management for a resident who requires such services.

10/12/2212/6/22
2 - Minimal harm or potential for actual harm
Few

Provide care and assistance to perform activities of daily living for any resident who is unable.

10/12/2212/6/22
2 - Minimal harm or potential for actual harm
Few

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

10/12/229/13/22
3 - Actual harm
Few

Provide safe, appropriate pain management for a resident who requires such services.

3/5/184/6/18
2 - Minimal harm or potential for actual harm
Few

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

3/5/184/6/18
2 - Minimal harm or potential for actual harm
Some
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide and implement an infection prevention and control program.

5/20/226/7/22
2 - Minimal harm or potential for actual harm
Few
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure services provided by the nursing facility meet professional standards of quality.

3/5/184/6/18
2 - Minimal harm or potential for actual harm
Some

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

3/5/184/6/18
2 - Minimal harm or potential for actual harm
Few

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

3/5/184/6/18
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Reasonably accommodate the needs and preferences of each resident.

3/5/184/6/18
2 - Minimal harm or potential for actual harm
Few
Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure each resident’s drug regimen must be free from unnecessary drugs.

3/5/184/6/18
2 - Minimal harm or potential for actual harm
Few

Ensure that residents are free from significant medication errors.

10/12/2212/6/22
2 - Minimal harm or potential for actual harm
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.

3/5/184/6/18
2 - Minimal harm or potential for actual harm
Few

Ensure that residents are free from significant medication errors.

3/5/184/6/18
2 - Minimal harm or potential for actual harm
Some

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

10/12/2212/6/22
2 - Minimal harm or potential for actual harm
Some
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
No Administration Deficiencies were found during this inspection period.
Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide routine and 24-hour emergency dental care for each resident.

4/28/226/7/22
2 - Minimal harm or potential for actual harm
Few

Provide safe, appropriate pain management for a resident who requires such services.

10/12/2212/6/22
2 - Minimal harm or potential for actual harm
Few

Provide care and assistance to perform activities of daily living for any resident who is unable.

10/12/2212/6/22
2 - Minimal harm or potential for actual harm
Few

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

10/12/229/13/22
3 - Actual harm
Few

Ensure that residents are free from significant medication errors.

10/12/2212/6/22
2 - Minimal harm or potential for actual harm
Some

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

10/12/2212/6/22
2 - Minimal harm or potential for actual harm
Some
Infection control inspection deficiencies in the past 3 years
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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.

6/30/237/20/23
2 - Minimal harm or potential for actual harm
Few

Develop and implement policies and procedures for flu and pneumonia vaccinations.

6/30/237/20/23
2 - Minimal harm or potential for actual harm
Few

Provide and implement an infection prevention and control program.

5/20/226/7/22
2 - Minimal harm or potential for actual harm
Few
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