Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ignite Medical Mchenry during CMS and state inspections, most recent first.
A cognitively intact post–joint replacement resident with an order for PRN oxycodone-acetaminophen every 4 hours reported requesting pain medication from a CNA during shift change but did not see a nurse for approximately 1.5 hours, during which her pain escalated to 7/10. The LPN who eventually assessed her stated they had not been informed of the earlier request, and documentation showed a 6.5-hour gap between PRN doses despite the every-4-hours order. The DON confirmed that CNAs are expected to notify nurses of pain complaints and that the care plan required immediate response to any pain complaint, but this did not occur.
A resident with multiple respiratory and cardiac conditions did not receive prescribed doses of Incruse Ellipta inhaler for several days after admission. Staff interviews revealed confusion about medication availability and administration, with the inhaler remaining unopened and only two doses given during a six-day stay, despite physician orders for daily use.
A resident with diabetes and other medical conditions did not receive three prescribed doses of Insulin Glulisine, despite elevated blood sugar levels that required insulin per physician orders. Staff interviews revealed that the insulin was not available and that there was a lack of immediate communication with the provider to obtain new orders, resulting in a significant medication error.
A resident who is incontinent and fully dependent on staff for ADLs was found in bed with saturated linens and a strong, foul odor, indicating they had not been changed in accordance with the facility's policy of providing incontinence care every two hours or as needed. CNAs present were unaware of when the resident was last changed, and the assigned CNA reported the last change was several hours prior, contrary to established protocols.
A resident with ADHD, traumatic brain injury, and dementia had her psychiatric medication discontinued without notification to her, her family, or her psychiatrist. The medication was stopped based on a physician's note, and the facility administrator confirmed there was no documentation of required notifications.
Two residents using CPAP machines did not have physician orders for their use, despite documentation of CPAP dependence and nightly use. Staff relied on family members for setup and did not consistently assist with application or ensure orders were in place, and the facility's policy did not address the requirement for physician orders for respiratory treatments.
A resident was administered psychotropic medications, including quetiapine, escitalopram, and trazodone, without obtaining proper consent from the resident or responsible parties prior to administration. Consent forms were either unsigned or signed after the medications had already been given, contrary to facility policy and staff expectations.
A resident with significant mobility and health issues, identified as high fall risk, experienced two falls. After each incident, the care plan was not updated to include new or individualized fall prevention interventions, despite facility policy requiring such updates.
The facility failed to follow physician orders for pressure ulcer care for two residents. One resident's sacral dressing was not changed as scheduled, and another resident's wound care orders were not properly documented or followed. Both residents were cognitively intact and had care plans addressing their pressure injuries, but the facility's inconsistent adherence to treatment protocols led to deficiencies.
A resident's midline catheter dressing was not changed according to standard practice, resulting in a saturated dressing with dried blood. The facility's policy requires dressing changes every seven days or as needed, but staff were unaware of the catheter's insertion date and the need for a change. The resident's physician orders lacked specific instructions for dressing care, leading to the oversight.
A facility failed to provide adequate ADL assistance for a resident with multiple health issues, including chronic kidney disease and heart failure. The resident required assistance for personal hygiene and bed mobility. A CNA found the resident's incontinence brief saturated with urine and the blanket underneath soiled. Despite this, the CNA left the resident on the soiled blanket, contrary to the facility's policies on ADL care and linen management.
The facility failed to provide adequate pressure ulcer care and prevention for two residents, resulting in deficiencies. One resident had a stage four pressure injury with a saturated dressing that was not changed as needed, and her heels were unprotected. Another resident had a painful open area without a dressing, and her heels were also unprotected. The facility's wound care protocols were not followed, leading to inadequate management of pressure injuries.
The facility failed to properly use PPE and perform hand hygiene for residents on enhanced barrier precautions. A CNA did not change gloves or wear a gown while providing care to three residents with conditions requiring such precautions, including MRSA and ESBL resistance. The DON confirmed the need for proper glove and gown use, as outlined in the facility's infection control policy.
The facility failed to properly store and label refrigerated foods and did not ensure staff wore hairnets correctly, affecting all residents. A surveyor found raw chicken and sliced ham improperly covered and a pork loin without a label. Additionally, a dietary aide was observed with hair outside the hairnet while working in the kitchen, contrary to facility policy.
A resident with a stage II pressure injury did not receive timely treatment upon readmission to the facility. The wound was identified, but no treatment was applied or documented until two days later, contrary to the facility's wound care policy. The lapse occurred because the nurse did not contact the wound care nurse or the resident's provider for treatment orders.
A resident with dysphagia and other medical conditions was left unsupervised while eating, despite requiring one-to-one feeding assistance. The resident was observed coughing and using a suction tube independently, highlighting a lack of adherence to posted swallow precautions and facility policy.
The facility failed to monitor two residents during medication administration. One resident had medications left at her bedside, leading to pills being dropped and not taken. Another resident had a cup of pills left on her refrigerator without proper authorization. The facility's policy requires nurses to observe residents taking medications, which was not adhered to in these cases.
The facility failed to maintain proper isolation precautions for two residents, leading to potential cross-contamination. One resident on contact isolation for ESBL did not have appropriate signage or PPE for six days, and staff inconsistently used PPE. Another resident on contact isolation for C-diff had a nurse enter without wearing required PPE. The facility's infection control policy was not followed in both cases.
Failure to Provide Timely PRN Pain Medication Following Resident Request
Penalty
Summary
The deficiency involves the facility’s failure to provide timely administration of PRN pain medication to a cognitively intact female resident admitted after joint replacement surgery with a left artificial hip joint. Upon admission, the resident had an order for Oxycodone-Acetaminophen 10-325 mg to be given every 4 hours as needed for pain, and her initial care plan directed staff to respond immediately to any complaint of pain. On the evening in question, the resident reported that around 7:00 PM she told a CNA she needed pain medication and was informed it was shift change and it might be a little while before the nurse came. The resident stated that she did not see anyone until approximately 8:30 PM, at which time she reported her pain as 7/10 and appeared grimacing and agitated. The resident’s family member, who was on the phone with the resident at about 8:30 PM, corroborated that the resident said she had requested pain medication at 7:00 PM and had not seen anyone since. The LPN who entered the room around 8:30 PM stated they were not informed in report or by a CNA that the resident had requested pain medication earlier and indicated they would have administered it sooner if they had known. Documentation showed the resident received Oxycodone just before 2:00 PM and then not again until 8:30 PM, a 6.5-hour interval, despite the order allowing dosing every 4 hours as needed. The DON stated that a resident’s pain level is what they say it is and that CNAs are expected to notify the nurse when a resident requests pain medication so the nurse can act, underscoring that this communication did not occur as required by the resident’s care plan and the facility’s pain management policy.
Failure to Administer Medication per Physician's Orders
Penalty
Summary
The facility failed to ensure that medications were administered to a resident according to physician's orders. A resident with multiple diagnoses, including interstitial pulmonary disease, COPD, chronic respiratory failure, congestive heart failure, and pulmonary hypertension, was admitted to the facility and had a physician's order for Incruse Ellipta inhalation to be given once daily for COPD. Review of the medication administration record showed that the resident did not receive the prescribed inhaler from 11/28 to 12/1, resulting in four missed doses. Interviews with the resident's significant other and nursing staff confirmed that the medication was not administered as ordered, with the inhaler remaining unopened for several days after admission. Staff interviews revealed confusion regarding the availability and administration of the medication. The resident's significant other reported being told by nursing staff that the inhaler was not available due to a need for prior authorization, and that the medication was not on the nurse's schedule to administer. Nursing staff acknowledged that only two doses had been used during the resident's six-day stay, and the DON stated that medications should be available upon admission and that nurses are expected to communicate when medications are not available. The facility's policy requires all medications to be administered as ordered by a healthcare professional.
Significant Medication Error Due to Missed Insulin Doses
Penalty
Summary
A resident with diagnoses including type 2 diabetes, cerebral infarction, dementia without behaviors, and atrial fibrillation was admitted to the facility with physician's orders for Insulin Glulisine to be administered three times daily per sliding scale. On one day, the resident did not receive any of the prescribed insulin doses, despite having elevated blood sugar readings between 240-365 that would have required insulin administration according to the physician's orders. The medication administration record confirmed that three doses were missed. Interviews with staff revealed that medications for new admissions typically arrive the next morning, and if a medication such as insulin is not available, the provider and pharmacy should be notified immediately. The LPN stated that the resident's insulin was not given due to insurance issues and that the provider should have been contacted for new orders. The DON indicated that prior authorization for medications is usually addressed before admission and was unaware of any such requirement for this resident. Facility policy requires that all medications be administered as ordered and that staff should check for misplaced medications and contact the pharmacy if a medication is unavailable. The failure to administer insulin and to communicate promptly with the physician constituted a significant medication error.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A resident who is incontinent of urine and dependent on staff for activities of daily living, including toileting and hygiene, was found lying in bed with a strong, foul odor present in the room. Upon observation, the resident's brief, pad, and sheet were saturated with dark, foul-smelling urine, with the saturation reaching through to the mattress. Certified Nursing Assistants (CNAs) present at the time of observation stated they had not changed or assisted in changing the resident earlier that day and were unaware of when the resident was last changed. The CNA assigned to the resident reported that the last change occurred at approximately 7:30 AM, despite facility policy and the Director of Nursing stating that incontinent residents are to be changed every two hours and as frequently as needed. The resident's care plan confirms total dependence on staff for toileting and hygiene, and the facility's incontinence care policy requires residents to be kept dry, comfortable, and odor-free.
Failure to Notify of Psychiatric Medication Discontinuation
Penalty
Summary
The facility failed to notify a resident, the resident's physician, and a family member when the resident's psychiatric medication was discontinued. The resident, who has a history of ADHD, traumatic brain injury, and dementia, was found to have her lisdexamfetamine stopped based on a physician's progress note, which indicated the medication should be discontinued. The resident's husband reported not being informed of this change and only learned about it after contacting the psychiatrist, who stated the treatment should not have been stopped. The facility administrator confirmed there was no documentation showing that the resident or family was notified of the medication change.
Failure to Obtain Physician Orders for CPAP Use
Penalty
Summary
The facility failed to ensure that two residents using CPAP (Continuous Positive Airway Pressure) machines had appropriate physician orders for their use. One resident reported that their family set up the CPAP machine and that the facility only assisted by providing distilled water, with no physician order present for the device. The respiratory therapy staff confirmed that they do not manage residents' personal CPAP machines and that nursing staff are responsible for obtaining physician orders, which should include the prescribed settings. However, review of the resident's records showed no physician order for the CPAP machine. Another resident's spouse stated that they brought the CPAP machine to the facility and instructed a CNA on its use, but observed that the machine was not used as intended and that staff did not assist with its application at night. The resident's records, including hospital discharge instructions and nurse practitioner notes, indicated CPAP dependence and nightly use, but there was no physician order for the CPAP during the resident's stay. The facility's respiratory supplies policy did not address the need for a physician order for respiratory treatments.
Failure to Obtain Consent Prior to Administering Psychotropic Medications
Penalty
Summary
The facility failed to obtain proper consent prior to administering psychotropic medications, including anti-psychotic, anti-anxiety, and anti-depressant drugs, to a resident. Review of the resident's records showed that medications such as quetiapine, escitalopram, and trazodone were administered before signed or verbal consent was obtained from the resident or their responsible parties. Consent forms for these medications were either unsigned or signed after the medications had already been given. Family members and the resident were unaware of having provided consent prior to administration, and facility documentation did not show evidence of verbal consent being obtained. The resident in question had recently returned from a hospital stay and was prescribed escitalopram and trazodone upon discharge, but not quetiapine. Despite this, the facility administered quetiapine without prior consent. The facility's own policy requires that psychotropic medications be initiated only after informed consent is obtained from the resident or their representative. Interviews with staff confirmed that consent should be obtained before administering such medications, regardless of prior hospital use.
Failure to Update Fall Interventions After Resident Falls
Penalty
Summary
A resident with multiple medical conditions, including muscle weakness, unsteadiness, reduced mobility, cellulitis, end stage renal disease, and a need for assistance with personal care, was admitted to the facility and identified as a high fall risk based on an initial Fall Risk Evaluation. Despite this high risk, the resident experienced two falls: one unwitnessed fall in her room and a second witnessed fall while transferring into bed. Following both incidents, the resident's Fall Risk Care Plan, which initially included only standard admitting interventions, was not updated to reflect the new falls or to add individualized interventions. The facility's Fall Prevention policy requires that safety interventions be added to the care plan for residents at risk for falls and that interventions be individualized. However, no changes or additions were made to the care plan after either fall, as confirmed by record review and staff interview.
Failure to Follow Physician Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure proper pressure ulcer care for two residents, leading to deficiencies in following physician orders for pressure injuries. For one resident, identified as R2, the wound care nurse was observed changing a sacral dressing that was dated four days prior, with stool present on the dressing. The resident reported that the dressings had only been changed a few times since his admission, and the wound care nurse confirmed that he had been on vacation for two weeks, leaving the responsibility to floor nurses. The treatment administration record (TAR) showed missed dressing changes on several dates, indicating a lack of adherence to the prescribed schedule. Another resident, identified as R1, reported that his sacral dressing had not been changed in over a week. The physician's order for R1's wound care, which included specific instructions for cleansing and dressing changes, was not reflected in the TAR. The wound care nurse confirmed that the orders were not entered as directed by the wound care doctor, who was new to the facility. The TAR showed inconsistencies in the documentation of dressing changes, with several shifts not signed off as completed. Both residents were cognitively intact and had care plans that included interventions for their pressure injuries. The facility's skin policy and procedure emphasized the need for appropriate treatment and services to promote healing and prevent further skin integrity issues. However, the lack of adherence to physician orders and inconsistent documentation of wound care interventions contributed to the deficiencies observed during the survey.
Failure to Change Midline Catheter Dressing as Required
Penalty
Summary
The facility failed to ensure that a resident's midline catheter dressing was changed according to standard practice. On January 13, 2025, a resident was observed with a midline catheter in the right arm, with a gauze dressing that was visibly saturated with dried blood and dated January 9, 2025. The resident mentioned that the catheter was inserted at the hospital before being discharged to the facility for antibiotic treatment. The facility's policy requires that midline dressings be changed every seven days or as needed if the dressing is loose or soiled to prevent infection. Interviews with the facility's nursing staff revealed a lack of awareness regarding the resident's catheter insertion date and the need for a dressing change. A registered nurse confirmed the dressing was overdue for a change and noted the presence of oozing at the site. The Director of Nursing stated that the facility's policy includes checking the site for infection signs and changing the dressing as needed. However, the resident's physician orders did not include specific instructions for dressing changes, contributing to the oversight.
Failure to Provide Adequate ADL Assistance and Linen Management
Penalty
Summary
The facility failed to provide adequate ADL assistance for a resident who required it, as observed during a survey. A resident, admitted with multiple diagnoses including chronic kidney disease, diabetes mellitus, and heart failure, was noted to have an ADL self-care performance deficit and limited physical mobility. The resident's care plan indicated the need for one staff member for personal hygiene and dressing, and two staff members for bed mobility and toileting. On a specific day, a CNA provided incontinence care and found the resident's incontinence brief saturated with dark urine, with urine also noted on the blanket underneath. Despite acknowledging the resident as a 'heavy wetter' and the resident expressing discomfort from being in bed too long, the CNA laid the resident back onto the soiled blanket and left the room without replacing it. This action was contrary to the facility's ADL policy and Linen Management Infection Control policy, which require care according to individualized care plans and proper handling of soiled linens.
Deficient Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to implement appropriate pressure ulcer care and prevention measures for two residents, R2 and R4, leading to deficiencies in their care. R2 was admitted with a stage four pressure injury to her sacrum and was at high risk for developing further pressure injuries. Despite having a care plan in place, R2's dressing was not changed as needed, resulting in a saturated and malodorous dressing. Observations revealed that R2's heels were not protected as required, and the wound care nurse acknowledged that the dressing should have been changed when it became soiled. R4, who had a history of pressure injuries, was also found to have inadequate care. Her care plan indicated a need for specific dressing changes to her right ischial tuberosity, but on observation, there was no dressing in place, and she complained of pain. The wound care nurse was unaware of the missing dressing and emphasized the importance of dressing changes to prevent wound deterioration. R4's heels were also unprotected, contrary to the facility's protocols. The facility's wound care program policy outlines the necessity for regular skin assessments and the implementation of risk reduction measures, such as heel protectors and repositioning. However, these protocols were not followed for R2 and R4, resulting in deficiencies in their care. The facility's failure to adhere to its own policies and procedures contributed to the inadequate management of pressure injuries for these residents.
Inadequate Use of PPE and Hand Hygiene in Infection Control
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, specifically in the use of personal protective equipment (PPE) and hand hygiene, for residents on enhanced barrier precautions. Three residents, identified as R2, R3, and R4, were involved in these deficiencies. R2, who was on contact isolation for MRSA in a wound, was observed receiving incontinence care from a CNA who did not change gloves or perform hand hygiene after touching various surfaces and the resident's body. Similarly, R4, who had pressure injuries and was under enhanced barrier precautions, received care from the same CNA who failed to change gloves or wear a gown while performing incontinence care and subsequently touching the resident's face. R3, diagnosed with ESBL resistance and requiring enhanced barrier precautions, also received inadequate care from the CNA, who did not change gloves, perform hand hygiene, or wear a gown while providing peri care. The Director of Nursing confirmed that gloves should be changed and hands cleaned after touching dirty items and before touching clean items, and that gowns and gloves should be worn for residents on enhanced barrier precautions. The facility's policy on enhanced barrier precautions emphasizes the use of targeted gown and glove use during high-contact resident care activities to prevent the transmission of multidrug-resistant organisms.
Deficiencies in Food Storage and Hairnet Use
Penalty
Summary
The facility failed to ensure proper storage and labeling of refrigerated foods and did not enforce the use of hairnets in the kitchen, affecting all residents. During a kitchen tour, a surveyor observed a pan of raw chicken thighs marinating in a metal pan with loose saran wrap, exposing the chicken. The pan was labeled with a prepared date of 8/13/24 and a use-by date of 8/19/24, but the chicken was not frozen by the use-by date. Additionally, a tray of sliced ham was found with loose saran wrap, exposing the meat, which was used for the noon meal. A large pork loin was also found without a proper label, only marked with a '16' in marker, indicating it was placed in storage on 8/16. The facility's policies require refrigerated foods to be labeled with discard or use-by dates and to be tightly wrapped to prevent contamination. Furthermore, a dietary aide was observed with her hair outside of the hairnet while working in the food preparation area. The aide moved throughout the kitchen with her hair exposed until the surveyor pointed it out to the dietary manager. The facility's policy mandates that all food and nutrition services employees wear hair restraints to prevent hair from falling into the food. These deficiencies in food storage and personal hygiene practices were identified during the survey, highlighting lapses in adherence to the facility's established policies.
Failure to Implement Timely Pressure Ulcer Treatment
Penalty
Summary
The facility failed to implement a treatment for a stage II pressure injury for a resident, identified as R49, for two days. R49 was readmitted to the facility after being hospitalized for a lung abscess and diarrhea. Upon readmission, an admission note documented open areas and redness on the sacrum, but no treatment was applied or notifications made. The sacral wound was later assessed as a stage II pressure injury by the Certified Wound Care Nurse, V5, on 8/12/24, two days after the initial identification. The facility's Wound Policy and Procedure requires that any resident with a wound receives treatment and services consistent with their goals of treatment, including notification of any skin impairment identified on admission. However, the nurse who identified the wound did not call the wound care nurse or the resident's provider for treatment orders, nor did they apply or document any treatment. The first documented wound treatment was not completed until 8/14/24, indicating a lapse in the facility's adherence to its wound care policy.
Failure to Supervise Resident with Swallow Precautions
Penalty
Summary
The facility failed to provide adequate supervision for a resident with swallow precautions, leading to a deficiency in ensuring a safe eating environment. The resident, who had diagnoses including Parkinson's disease, pneumonitis due to inhalation of food and vomit, chronic obstructive pulmonary disease, and dysphagia, was observed eating alone in his room despite having a posted requirement for one-to-one feeding assistance. The resident was intermittently coughing while feeding himself and was using a suction tube independently, indicating a lack of supervision and assistance during meals. Staff interviews revealed that the resident had been evaluated by a speech therapist and required assistance with meals due to poor attention and impulsivity, making it unsafe for him to eat alone. Despite this, the resident was left unattended with his breakfast tray, contrary to the facility's policy and the posted swallow precautions. The Director of Nurses and Corporate Nurse acknowledged that staff should have been present at all times for residents requiring one-to-one feeding assistance to prevent potential choking hazards.
Failure to Monitor Medication Administration
Penalty
Summary
The facility failed to properly monitor residents during medication administration, leading to deficiencies in the care of two residents. Resident 1, who has chronic obstructive pulmonary disease, type 2 diabetes mellitus, congestive heart failure, and chronic lymphocytic leukemia, reported that a night nurse left her morning medications at her bedside without ensuring they were taken. This resulted in medications being dropped and not consumed, as evidenced by a pill found on her bed. The facility's policy requires that medications should not be left at the bedside unless there is a physician's order, and the nurse must observe the resident taking the medication. Similarly, Resident 32 was found with a cup containing at least 12 pills left on her refrigerator, which she preferred to take after eating. There were no care plan interventions or physician orders allowing medications to be left at her bedside. The Director of Nursing confirmed that nurses should monitor residents while they take their medications and that medications should not be left unattended. The facility's procedure mandates that staff remain with the resident to ensure medication is swallowed, which was not followed in these instances.
Failure to Maintain Isolation Precautions
Penalty
Summary
The facility failed to maintain proper isolation precautions for two residents, leading to potential cross-contamination. Resident R61, who was on contact isolation for ESBL in her urine, did not have appropriate signage or personal protective equipment (PPE) available outside her room for six days after the order was given. The resident's room lacked a biohazard bin for used PPE, and there was inconsistency among staff in wearing gowns and gloves when entering the room. The facility's policy required immediate implementation of contact isolation precautions, including signage and PPE availability, which was not followed. Similarly, Resident R49, who was on contact isolation for C-diff, had a sign indicating the need for gowns and gloves upon room entry. However, a Certified Wound Care Nurse entered the room without wearing the required PPE and touched the resident's bedding. The facility's infection control policy mandates the use of gowns and gloves to prevent the spread of infections, especially for residents with multi-drug resistant organisms. The Director of Nursing acknowledged the importance of these precautions, which were not adhered to in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mchenry
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alden Terrace Of Mchenry Rehab | 1.2 mi | — | 5 | 0 |
| Pearl Of Crystal Lake, The | 3.6 mi | — | 0 | 0 |
| Fair Oaks Health Care Center | 5.7 mi | — | 2 | 0 |
| Crystal Pines Rehab & Hcc | 7.3 mi | — | 4 | 0 |
| La Bella Of Woodstock | 8 mi | — | 12 | 0 |
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