Inspection·June 10, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interviewed by our staff and she stated that (R1) was outside and she asked if she needed help and (R1) said she was here visiting and her ride hadn't shown up yet so (V7) offered her a ride. (R1) was able to tell (V7) her daughter's address so that's where (V7) took her. I was told that (R1) had been overall calm until that morning when she had her bags packed and was saying things like this was a nice visit but it's time for me to go home now. Had I known about those statements I probably would have put her on a 1:1 or 15-minute checks because she was obviously trying to leave the facility. I was the one who initially put (R1's) (departure alert system) on her. I did not test the alarm when I put it on her because it was brand new, so I assumed it was activated and ready to go. Surveyor was not able to view camera footage and did not receive a return call from V7 for interview. On 6/10/24 at 1:01PM, V4 (R1's Daughter) stated To my knowledge she was fine and secure and safe at the facility on Friday. At around 8:30AM, my neighbor knocked on the door and they said your mom is out here. I was shocked and she didn't know how she got there. (Facility) told me that someone that does not work for them but is a caregiver at the apartments next door, approached her outside and offered her help and gave her a ride to my house. This woman brought her to my house and just left. She didn't make sure she was ok, she just left. (Facility) called me around 9:00AM and asked if my mom was there and I said she was. I didn't call the facility to let them know she was here because that's not my responsibility. Nobody called me personally and let me know they were bringing her home. Apparently, this girl found my husband's social media account and sent him a message saying that she was dropping my mom off at our house. By the time he called me the facility was already calling me. It's the only place I really want her to be. My concern is that this person just took her from the grounds without even asking anyone or checking with the facility. My mom paces a lot on the sidewalk, but she has never left the property at home. My plan is to take her back there now that we have a good plan in place to keep her safe at (facility). On 6/10/25 at 1:59PM, V5 (Registered Nurse) stated, I checked on (R1) right before I went downstairs and told the aides to watch her because she had her bags packed. It was around 7AM and the alarm did sound for its routine test. It does a test at 7AM and 7PM and when staff silence the alarm they check in and outside the doors to make sure it was just the test and not a resident leaving. I'm not sure who was the one who responded to that 7AM alarm on the morning of the 6th but I remember watching them look outside the door to be sure there wasn't a resident there, specifically (R1) because she was agitated that morning. You don't have to do anything to reset it, you just put the code in, and it shuts the alarm off and it's already in activation status. (V6-Agency CNA) checked on her before breakfast and she was gone. She got on the walkie and asked if anyone had eyes on her. I don't know if she had tried to leave before, she was very pleasantly confused. We do (departure alert system) checks every night shift. There is a box we take around and we wave it around (departure alert system) and it will beep and if it doesn't you replace the (departure alert system). Our new process though is to check them every shift because (R1's) was checked on the 6/5 night shift and was working so I'm not sure why it didn't alarm. On 6/10/25 at 2:19PM, V6 (agency CNA) stated, (R1) was exit seeking that whole morning. She kept coming around us and had a bag and said she wanted to go to her daughter's house. She was up here around 7:30AM and was just sitting in her room when I went downstairs to help feed residents breakfast. There were 3 other aides upstairs still getting residents up for breakfast and there was a housekeeper on the hall, I think. I know there was also some administrative staff here so I felt confident that there were enough people upstairs to keep an eye on her plus she had the (departure alert system) on so that would notify us if she tried to leave. She hadn't set off any of the door alarms at all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145495 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Medina Nursing Center 402 South Center Street Durand, IL 61024 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that morning and she didn't try to get outside, she was just kind of lingering around doors. When I came back up around 8:19AM she was gone so I alerted the nurse. I searched the whole hallway, and we went over to apartment side and up the center hallway. Soon after that, we were notified that she was at her daughter's house and safe. I have no idea why her alarm did not go off because it's on her wrist, so we were able to see that it was still on her that morning. Looking back, we probably should have tried to take her down to breakfast with the first seating so we could keep a better eye on her. The facility's undated policy titled, Wandering, unsafe resident showed, The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for wandering .3. Staff will check each (departure alert system) on every resident weekly for proper working condition. If (departure alert system) is found to not be working properly, it will be replaced immediately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145495 If continuation sheet Page 3 of 3