Ignite Medical Hanover Park

Inspectors wroteBased on interview and record review, the facility failed to establish care schedules based on individual resident preferences and needs rather than staff convenience for 5 of 5 residents (R1, R2, R3, R7, and R8) in the sample of 5 reviewed for overnight care schedules. Specifically, timecard records revealed two dedicated wound nurses routinely initiated shift duties as early as 2:30 AM to perform non-emergent wound care while residents were sleeping, solely to accommodate employee personal and educational schedules. This deficient practice directly affected 83 residents with active wound care orders and had the potential to affect all 90 current residents in the facility should they require wound care services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a functional Restorative Nursing Program was maintained and executed to ensure residents maintain functional abilities and range of motion in accordance with comprehensive assessments and care plans. Specifically, the facility failed to allocate dedicated restorative nursing personnel, maintain supervisory oversight, or deliver structured restorative interventions, and instead integrated restorative care tasks into general Certified Nursing Assistant Point of Care electronic documentation, relying on unverified check-box entries without confirming session duration or care delivery. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sufficient number of nursing staff to ensure restorative care plans and scheduled therapeutic interventions were executed as ordered. Specifically, the facility failed to allocate designated Restorative Nursing Aides (RNAs) and failed to provide adequate floor nursing coverage to complete ordered restorative interventions. This failure resulted in omitted restorative care, unapplied adaptive prosthetics, and unfulfilled therapeutic exercise routines for 4 sampled residents (R4, R5, R6, R7) reviewed for sufficient nursing staff, affected 27 residents on the restorative roster, and had the potential to affect all 90 residents residing in the facility. On 7/27/26 at 10:10 AM, V1 (Administrator) provided the facility census roster showing 90 current residents residing in the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a comprehensive care plan was implemented for 4 of 4 residents (R4, R5, R6, R7) reviewed for care plan implementation in the sample of 8. Specifically, the facility failed to ensure that individualized care plan interventions-including restorative nursing programs for dressing, grooming, ambulation, transfers, active range of motion, and bed mobility-were executed and provided as care planned. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received necessary care and services to maintain optimal personal hygiene, grooming, and physical functioning. Specifically, the facility failed to ensure ordered adaptive prosthetic equipment was applied, hygiene and grooming care plans were executed, and therapeutic exercise regimes were carried out as ordered. This resulted in unmet personal hygiene needs, unapplied prosthetics, and omitted therapeutic care for 4 of 4 residents (R4, R5, R6, R7) reviewed for quality of care in the sample of 8. On 7/28/26 at 2:15 PM, V12 (Restorative/MDS Coordinator) was interviewed and stated the facility does not operate an active Restorative Nursing Program or employ designated Restorative Nursing Aides. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications as ordered by physician. There were 25 opportunities with five errors resulting in a 20% (percent) error rate. This deficiency affects four (R38, R74, R82 and R88) of 15 residents in the sample of 45 observed during medication pass.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policies related to hand hygiene, hand washing, and use of gloves during medication administration; the facility failed to ensure glucometers were sanitized after use according to manufacturer's guidelines. These deficiencies affected eight (R23, R38, R49, R74, R82, R86, R99, R125) of 15 residents in the sample of 45 reviewed for infection control.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label residents' medications when opened. This applies to 4 out of 4 (R78, R91, R13, and R27) residents reviewed for medications in a sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess residents to self-administer medications. This applies to 2 of 2 residents (R27, R84) reviewed for self-administration of medications in a sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to utilize assistive devices to prevent furthering worsening of contractures. This applies to 1 of 3 residents (R10) reviewed for restorative care in a sample of 23.

Inspectors wroteBased on observation, interview and record review the facility failed to implement safety measure for a resident with a history of falls with injury. This applies to 1 of 3 residents (R294) reviewed for accidents in a sample of 23.

Inspectors wroteBased on interview and record review, the facility failed to provide nutritional supplements for a resident who was losing weight. This applies to 1 of 3 residents (R67) reviewed for weight loss in a sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders and care plan interventions to administer oxygen therapy. The facility also failed to provide humidification with oxygen therapy by using an empty humidifier bottle with oxygen therapy. This applies to 1 of 2 residents (R60) reviewed for respiratory care in a sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to reorder residents' prescribed medications. This applies to 3 out of 4 (R15, R27, and R13) reviewed for pharmacy services in a sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications as ordered. There were 38 opportunities with 4 errors resulting in a 10.53% error rate. This applies to 3 out of 4 (R15, R90, and R27) residents observed in the medication pass in a sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were changed in a timely manner for 1 of 9 residents (R3) reviewed for Activities of Daily Living (ADL) in the sample of 9.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and/or follow Enhanced Barrier Precautions (EBP) for 3 of 3 residents (R1, R2, R3) reviewed for infection control in the sample of 9.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet resident ADL (Activities of Daily Living) cares for residents who need assistance with eating and showering. This applies to 5 of 7 residents (R2, R3, R4, R5, and R6) reviewed for ADLs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer and document scheduled medications as ordered for residents. The facility also failed to reorder residents' prescribed medications. This applies to 10 of 14 residents (R1, R9, R10, R11, R14, R15, R16, R17, R18, and R19) reviewed for medication services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor a resident's (R6) blood glucose level as ordered. This applies to 1 of 4 residents (R6) reviewed for quality of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to promptly respond to residents' call lights when residents require assistance with ADLs (Activities of Daily Living). This applies to 6 of 6 residents (R4, R9, R10, R12, R13, R14) reviewed for timely call light response and ADL care in the sample of 14.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's call light was within reach for two residents (R2 and R74) reviewed for accommodation of needs in a sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable, appropriately lit environment for residents. This applies to one resident (R19) reviewed for homelike environment in a sample of 25.

Inspectors wroteBased on interview and record review, the facility failed to refer a resident for level II PASARR (Pre admission Screening and Resident Review) evaluation and determination who was recently diagnosed with newly evident MD (Mental Disorder). This applies to one resident (R38) reviewed for PASARR in a sample of 25.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow professional standards of care while performing blood sugar checks on residents. This applies to two of five residents (R54, R84) reviewed for blood glucose monitoring in a sample of 25.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervisvion and assistance to prevent falls. This applies to one residents (R14) reviewed for accident hazards in a sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's pain was managed. This failure resulted in a resident experiencing pain rated at 10 out of 10. This applies to 1 resident (R28) reviewed for pain management in a sample of 25.

Inspectors wroteBased observation, interview, and record review, the facility failed to remove expired items from and clean resident refrigerators. This applies to one of one resident (R37) reviewed for personal refrigerators in a sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide toileting hygiene for residents who required assistance with incontinence care. This applies to 4 of 4 residents (R1, R2, R4, R5) reviewed for ADL's (Activities of Daily Living) in the sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer insulin as ordered. This applies to one of three residents (R1) reviewed for insulin administration in the sample of five.