Medina Nursing Center

Inspectors wroteBased on interview and record review the facility failed to protect residents from verbal abuse from staff. This applies to 2 of 4 residents (R1, R2) reviewed for abuse in the sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Illinois Department of Public Health survey results were accessible to residents. This failure affects all residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the nurse daily staffing was posted on a daily basis. this applies to all residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide a bed hold policy and written notice of transfer to 4 of 4 residents (R1,R15,R35,R41) reviewed for hospitalizations in the sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a wheelchair to enable a resident to self-propel for 1 resident (R19), failed to provide foot pedals for a resident's (R19) wheelchair. These failures apply to 1 of 1 residents reviewed for accomodation of needs in the sample of 23.

Inspectors wroteBased on observation, interview, and record review the facility failed to attempt a reduction of a resident's restraint and release the restraint when supervised for 1 of 1 residents (R3) reviewed for restraints in the sample of 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain weekly weights as ordered by the physician for 1 of 1 resident (R43) reviewed for quality of care in the sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a restorative program tailored to a resident's needs for 1 of 2 residents reviewed for restorative therapy in the sample of 23.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was transferred using a gait belt and failed to ensure a resident was safely transported in a wheelchair for 2 of 6 resident (R43, R9) reviewed for safety in the sample of 23.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure cathter bags were covered and not resting on the floor for 2 of 2 residents (R2 & R21) reviewed for catheters in the sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply oxygen as ordered by a physician for 2 resident (R19,R49), failed to maintain oxygen concentrator per manufacturer's recommendations for 1 resident (R49), failed to change oxygen tubing per facility policy for 1 resident (R43). These failures apply to 3 of 3 residents reviewed for oxygen therapy in the sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform glove changes during wound care for 1 resident (R7), and failed to wear personal protective equipment during wound care for 1 resident (R15). These failures apply to 2 of 5 residents reviewed for infection control in the sample of 23

Inspectors wroteBased on interview and record review the facility failed to identify a resident's new, non-pressure wounds. The facility failed to perform weekly wound assessments on a resident's wounds. These failures resulted in R2 being hospitalized for cellulitis (bacterial skin infection) of his left foot after maggots were found in R2's left foot wounds. These failures apply to 1 of 3 residents (R2) reviewed for wounds in the sample of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement fall interventions and update a residents care plan for a resident with a history of falls (R1). The facility also failed to investigate a resident's falls, update their care plan, and implement fall interventions (R3) for a resident with a history of falls. This applies to 2 of 3 residents reviewed for falls in the sample of 4.

Inspectors wroteBased on interview and record review the facility failed to ensure personal alarms were working for a resident at risk for falls for 1 of 3 residents (R2) reviewed for falls and safety in the sample of five.

Inspectors wroteBased on observation, interview, and record review the facility failed ensure the safety of a dependent resident by not preventing a burn for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 sustaining a 2nd degree burn to his left knee.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was free from verbal abuse for 1 of 3 residents (R3) reviewed for abuse in the sample of 3.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the safety of a dependent resident who was left outside in the sun for two hours without water or a way to call for help. This applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 6. This failure resulted in R1 being transferred to an acute care hospital for treatment of heat exhaustion, sun burn, hypoxia, and altered mental status. The Immediate Jeopardy began on 9/14/25 when R1 was assisted outside in her reclining wheelchair and placed directly in the sun without staff supervision and monitoring in place for two hours. V2 (Assistant Administrator) was notified of the Immediate Jeopardy on 9/19/25 at 11:25 AM. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free from verbal abuse for 1 of 3 residents (R1) reviewed for abuse in the sample of 7.

Inspectors wroteBased on interview and record review the facility failed to ensure an allegation of abuse was reported immediately for 1 of 3 residents (R1) reviewed for abuse in the sample of 7.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free of theft by a visitor for 1 of 3 residents (R1) reviewed for theft in the sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident (R1) with a high elopement risk was supervised. This applies to 1 of 3 residents reviewed for safety and supervision in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to ensure staff reported resident bruising for 1 of 6 residents (R1) reviewed for abuse in the sample of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to transfer a resident in a safe manner for 1 of 6 residents (R1) reviewed for safety in the sample of 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods were discarded on or before their use by date, failed to ensure employee food was not stored with food to be used for residents, and failed to label and date foods in the refrigerator. These failures have the potential to affect all 46 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to assess the need for a pommel cushion in a resident's reclining wheelchair prior to use, failed to obtain a physician's order for the use of the cushion and failed to document the intervention in R21's care plan. This applies to 1 of 12 residents (R21) reviewed for restraints in the sample of 12.

Inspectors wrote2. R43's current order summary report printed on April 8, 2025 shows, lorazepam oral tablet 0.5 mg (milligrams), give 1 tablets by mouth every 4 hours as needed for anxiety, agitation, restlessness . The medication was ordered on March 13, 2025 and has no stop/end date. 3. R28's current order summary report printed on April 8, 2025 shows, lorazepam PLO (Pluronic Lecithin Organogel) 1 mg/ml (milligram/mililiter) administer topically as needed if not accepting Ativan tablet every 6 hours as needed for anxiety, agitation. The medication was ordered April 12, 2025 and has no stop/end date. R28's current order summary report printed on April 8, 2025 shows, lorazepam tablet 1 mg, give 1 mg by mouth every 8 hours as needed for anxiety . The medication was ordered on March 31, 2025 and has no stop/end date. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure opened insulin pens were labeled and expired insulin was discarded. This applies to 2 of 2 residents (R1 & R10) reviewed for medication labeling/storage in the sample of 12.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 5 residents (R9) reviewed for immunizations in the sample of 12 was offered and/or received the recommended pneumococcal immunizations.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement infection control interventions for a resident with a communicable disease for 1 of 8 residents (R7) reviewed for infection control in the sample of 8.

Inspectors wroteBased on observation, interview, and record review the facility failed to safely transfer residents by not using a gait belt and by pulling the emergency release of a full body mechanical lift for 2 of 3 residents (R1 and R2) reviewed for safety in the sample of 3.

Inspectors wroteBased on observation, interview, and record review the facility failed to safely control a full body mechanical sling lift resulting in R1 sustaining a laceration to her forehead, for 1 of 4 residents reviewed for mechanical sling lift transfers in the sample.

Inspectors wroteBased on interview and record review, the facility failed to perform a safe mechanical lift transfer for 1 of 3 residents (R12) reviewed for safety/supervison in the sample of 15 . This failure resulted in R12 experiencing a fall from the mechanical lift and sustaining a hematoma.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a urinary drainage bag was kept below the level of the bladder and failed to ensure a urinary drainage bag was kept off the floor for 1 of 2 resident (R18) reviewed for catheters in the sample 15.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent cross contamination when providing incontinence care and failed to ensure gloves were worn when an injection was given for 2 of 2 residents (R26 & R4) reviewed for infection control in the sample of 15.

Inspectors wroteBased on observation, interview and record review the facility failed to implement their antibiotic use criteria and monitor their use for 1 of 1 resident (R19) reviewed for antibiotics in the sample of 15.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was supervised and assisted as needed by staff while ambulating which contributed to R1 falling in the facility and sustaining a right hip fracture. This failure applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 6.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was free from verbal abuse for 1 of 4 residents (R4) reviewed for abuse in the sample of 6.