Ignite Medical McHenry: Resident Left Soaked in Urine - IL
It was 10:22 on a Monday morning. The resident, identified in the inspection report only as R5, was lying in bed. Two certified nursing assistants were already in the room to change her. What they found, and what federal inspectors documented, was a brief, a pad, and a sheet all saturated through with dark, foul-smelling urine. The urine had soaked all the way down to the mattress.
Seventeen minutes later, inspectors asked R5 directly what had happened. She said no one had changed her earlier that morning.
The nursing assistants in the room gave conflicting accounts. One, identified as V7, told inspectors she had not changed R5 earlier that day and did not know when R5 had last been changed. She said the resident belonged to a different aide's assignment. The aide assigned to R5, identified as V4, told inspectors at 12:33 PM that she and a coworker had changed R5 at around 7:30 that morning. That would mean nearly three hours had passed between changes, with no documentation that anyone had checked on her in between.
R5 had been incontinent of urine since at least October 2021, according to her care plan. A separate care plan entry from December 2023 noted she had a self-care performance deficit and was fully dependent on staff for toileting and toileting hygiene. She could not manage this herself. She required staff to do it for her.
The Director of Nursing, identified as V2, told inspectors that incontinent residents are supposed to be changed every two hours, and more often if needed. She said staff are trained to prioritize residents who cannot communicate that they are wet, changing those residents first. She said if a resident is changed and found wet again within an hour, staff must change them again immediately.
R5 is one of those residents. She is dependent. She cannot toilet herself. She had been lying in saturated bedding long enough for urine to soak through multiple layers of absorbent material and into the mattress itself.
The facility's own incontinence care policy, last reviewed in November 2024, states that incontinent residents are changed every two hours and more frequently if needed, and that the goal is to keep residents as dry, comfortable, and odor-free as possible.
The room smelled so strongly that inspectors noted it immediately upon entering.
The inspection was triggered by a complaint and conducted on August 11, 2025. Inspectors reviewed five residents for activities of daily living and cited this failure for one of them. The level of harm was classified as minimal harm or potential for actual harm, the lower end of the federal scale, affecting a small number of residents.
What the classification does not capture is what it means to lie in your own urine long enough for it to saturate through a pad, a brief, and a sheet and pool into the material beneath you. R5 had no way to change herself. She had no way to get dry. She had a care plan that documented her dependence and a facility policy that promised two-hour checks. Neither protected her that morning.
When inspectors left the room at 10:22, the two aides who had arrived to change her were still there, working through the damage. R5 had already told them what she told the inspector minutes later. Nobody had come earlier.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ignite Medical Mchenry from 2025-08-11 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 3, 2026 · Our methodology
IGNITE MEDICAL MCHENRY in MCHENRY, IL was cited for violations during a health inspection on August 11, 2025.
It was 10:22 on a Monday morning.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.