Ignite Medical Mchenry

In the surveyor’s words

From the most serious findings on record at Ignite Medical Mchenry, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jan 18, 2024

  Based on interview and record review, the facility neglected to identify that (R1) had a left ventricular assist device (LVAD), and neglected to ensure facility staff were trained on caring for (R1's) LVAD. These failures resulted in staff not assessing R1's LVAD and R1's LVAD depleting it's battery life and becoming non-operational. As a result, R1 was hospitalized for shock where he expired on [DATE]. The findings include: The Immediate Jeopardy began on [DATE] when R1 was admitted to the facility with an LVAD. V19 (General Manager) was notified of the Immediate Jeopardy on [DATE] at 12:00PM. […]

• Immediate jeopardy, isolatedF684Jan 18, 2024

  Based on interview and record review, the facility failed to monitor a resident's (R1) left ventricular assist device (LVAD) resulting in R1's LVAD device depleting it's batteries and R1 experiencing shock and being sent to the local hospital where he expired on [DATE]. The findings include: The Immediate Jeopardy began on [DATE] when R1 was admitted to the facility with an LVAD. V19 (General Manager) was notified of the Immediate Jeopardy on [DATE] at 12:00PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. […]

• Actual harm, isolatedF689Aug 14, 2023

  Based on observation, interview, and record review the facility failed to ensure R1 was showered in a safe manner for 1 of 5 residents (R1) reviewed for falls in the sample of 10. This failure resulted in R1 falling in the shower and sustaining fractures to the left arm. The findings include: On 8/14/23 at 8:58 AM, R1 was laying in bed with her left arm in a splint and a sling and her left foot with a dressing and foam cushioned boot on. R1 stated I fell in the shower. I was standing in the shower and the staff was drying me off. I was holding on to the rail, but I slipped on a towel or something trying to turn so the staff could dry me. I had no balance or support when turning. I fell on my right side with my left arm hanging onto the rail. When I took my arm down it really hurt. […]

• No harm, potential for more than minimal, widespreadF761Nov 20, 2025

  Based on observation, interview and record review the facility failed to store controlled drugs in a secure manner. This applies to all the residents in the facility.The findings include:The Centers for Medicare and Medicaid Services form 671 dated 11/18/2025 shows there were 84 residents in the facility. On 11/19/2025 at 2:00 PM the Medication room on the [NAME] unit was observed. In the unlocked refrigerator in the medication room, three convenience containers were observed to contain Lorazepam (a schedule class 4 controlled substance and an anti-anxiety medication). […]

• No harm, potential for more than minimal, widespreadF812Nov 20, 2025

  Based on observation, interview and record review the facility failed to maintain a sanitary kitchen environment. This applies to all the residents in the facility.The findings include:The Center for Medicare and Medicaid services form 671 dated 11/18/2025 shows there were 84 residents in the facility.On 11/18/2025 at 10:00AM, work surfaces in the kitchen, the floors of the kitchen, the floors of the dry storage, refrigerator and freezer were observed with food debris. The carts used to transport the resident food trays to the units were observed with dried food debris. A large pile of empty boxes and other garbage bags were observed within the kitchen on the floor. […]