Inspection·September 19, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few hands/arms. Skin: . Sunburn to her face, shoulders, and upper chest areas that were exposed with the shirt she is currently wearing. ED Course as of 9/14/2025. Patient presents with above complaint. Was apparently left outside for 2 hours today in the sun. Has sunburn to her face and upper body. I called and spoke with the nursing home. Reports that she was out there for 2 hours. Per the notes, the patient was initially unresponsive. She still seemingly somewhat confused here but is much more alert than arrival. She was hypoxic upon arrival, which has also improved. CMP with an elevated creatinine. Due to the hypoxia D-dimer was obtained which was elevated. Diagnosis: After the evaluation in the Emergency Department, my clinical impression is 1. Acute cystitis without hematuria, 2. Heat exhaustion, initial encounter, 3. Sunburn, 4. Hypoxia, 5. Altered Mental Status.R1's Acute Care Hospital documented dated 9/15/25 showed, Assessment and Plan: . [AGE] year-old female brought in from [nursing home] . for being left out in the sun too long. She was found to be confused, sun burned, and have signs of UTI/dehydration. We will admit. Vitals on arrival show soft/normal BP (blood pressure) 110s, low grade temp 99, slightly hypoxic to 88. Exam shows patient to be dry, sunburnt.On 9/17/25 at 10:02 AM, V6 CNA (Certified Nursing Assistant) said, [R1] asked me to push her outside after lunch. Then I asked her the time limit because it is usually 10-20 minutes. It wasn't all that hot right then. She asked for 20 minutes to be outside. I used the walkie (handheld communication device) and said [R1] was outside and wanted 20 minutes. When I went inside, I told the girls at the desk too. I honestly don't remember who was at the desk, I just know there were 2-3 people there. I told them she wanted 20 minutes. I worked that day from 4:00 AM -1:30 PM but I think I left at about 1:45 that day. [R1] was the last one to come up from lunch so it could have been anywhere from 1:15-1:30 PM that I took her outside. She usually sits right at the end by the entrance, I usually put her at the end, past the building, and face her toward the sun so she is still in eye view of the door. I don't know if I was just a hair off with where I put her, but I don't remember. She has a 10-20-minute time limit to be outside. She goes out for 10 minutes and when you check on her, she will sometimes ask for 10 minutes more. Usually someone sets a timer for that. I don't know if they set the timer that day or not. They usually have a timer on someone's phone in their pocket. She goes outside all the time, and it is common for staff to be watching for her.On 9/17/25 at11:03 AM, V11 CNA said, I heard [V6] on the walkie say she took [R1] out and for a timer to be set. I just don't remember if there was a response. If there is no response for me when I take [R1] out, I go to the CNA in person, otherwise, you set the timer yourself because you are the one that took her out. She always sits in the same general place outside. She never takes water out with her. She doesn't take a phone or anything out with her. She will tell us either 10 minutes or 20 minutes, but no longer than 20 minutes. We set that limit, especially if it is really hot outside. She can't call us if she wants to come in. The limit is set because of the weather, you can't be in the sun that long. On 9/17/25 at 11:11 AM, V12 CNA said, I wasn't really part of it. I heard [V6] get on the walkie and say she put her outside. Usually whoever puts her outside sets the timer and brings her back in. I'm pretty sure I heard a response on the walkie when [V6] said [R1] was outside, but I don't know who responded. I left at 3:30 PM so I wasn't there when they found her. She has 10-20 minutes is the usual. If it is really hot, we check on her at the 10 minutes. She is able to tell us if she is too hot. Then we give her another 10 minutes. If it is hot, 20 minutes is the maximum. When [R1] is outside, she wouldn't be able to let us know if she wanted to come in. That is probably why we do the 10-minute check in. She doesn't take drinks out with her because she can't hold them. On 9/17/25 at 11:30 AM, V9 CNA said, I worked Sunday (9/14/25), I heard [V6] say to put on a 10-minute timer. I was mid-conversation with a coworker so I can't 100% say if I heard a response. [R1's] CNA was sitting at the nursing station. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145495 If continuation sheet Page 2 of 5 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 09/19/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few I was here until 2:00 PM that day. Everyone here has a ‘walkie' and would hear that. It is a normal thing to hear. I will tell you what I do, if I take her outside, I put the timer on my own phone because I don't want someone to forget, and it be me that put her out there. If it rings (the timer) while I am in with another resident, I will ‘walkie' to someone to go get her or I will go out as soon as I'm done. If it is hot, we limit the time because of issues like this. She doesn't have water out there so we would go and bring her in, give her water, give her time to cool down. It is limited so these situations don't happen. There is no way for her to let anyone know she needs to come in, that is why she is checked on in 10-minute increments. Either someone forgot to set the timer or didn't hear their timer. There should be a better system, so these things don't happen.On 9/17/25 at 10:50 AM V10 CNA (Certified Nursing Assistant) said she worked 5:30 AM 5:30 PM on 9/14/25. V10 said, [R1] doesn't eat breakfast, so she got up for lunch. After lunch, I was not aware that someone put her outside. Someone wheeled her out there, I was not told she was out there. We had our shift change and one of the other CNA that had come in at 2:30 PM saw [R1] out there. We gave her water and we put cool, wet, towels on her. She was able to drink water. I told her to try and keep her eyes open. At first, she was really hard to get to respond but later she started to be more responsive. We got cold towels on her. We took her vitals. I don't remember what they were, the nurse should have the vitals somewhere. I was there immediately when she was brought in, she was red, warm, her eyes were closed, and we were shaking her to try and wake her up. She was in and out of consciousness until we started with the cold towels and water. After we started that, she started to be more responsive. We asked her if she had a headache, she said yes, really quickly and shut her eyes again. It took about 1-2 minutes before she started responding. There is no call light out there, we usually put a timer on our phone, and we go out and get her. I don't know who let her out or if there was a timer. No one reported to me she was outside. She doesn't take anything out to call us when she is ready. Usually whoever lets her out puts the timer on and will tell the person that has her assignment. Usually, it is whoever puts the timer on that is the one that goes back and gets her. I have never seen her take water out with her. I don't think she had any. She has trouble grabbing things so I don't know if she could even hold it. You maybe could see her when she is out there if you were looking out the window. It would depend on where you are at. For sure the cold towels and water helped. She was very thirsty, so we gave her a good amount of water. She was drinking water from the little plastic cups. She drank a few of those little cups. She kept drinking the water, so we kept giving her more. She was getting more conscious as she was leaving with the ambulance.On 9/17/25 10:10 AM, V5 CNA said, I found [R1] outside. No one had any idea that she was out there. No one mentioned in report when I came in that she was out there. Usually, whoever takes her outside, they are supposed to set a 20-minute timer. I came in at 2:30 and no one had any idea she was out there. I was taking another resident outside and I saw her. I didn't think anything of it at first, but I said ‘hi' to her and she didn't respond. Her eyes were rolled back, and she was twitching. She was unresponsive for quite some time until she got sent out. Everything was normal that day until that point. I don't know who took her outside. It was hot outside, probably about 85 degrees and she was in the direct sun. She wasn't in view of the door or anything either. I didn't see her until I fully walked outside, and she was off to the left side. It was 3:30 PM when I found her because I was telling the resident that I was taking outside that I had a specific amount of time before I had to be getting people up for dinner. I went outside with my other resident and when I found [R1] I immediately brought her in. The nurse and a couple of the other CNAs were putting cold wet towels on her, getting her vitals, and things like that. I didn't watch the full process. She was kind of going in and out of responsiveness (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145495 If continuation sheet Page 3 of 5 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 09/19/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few when I came back in. She would open her eyes and kind of look at you, but she wasn't verbal other than to say ‘what'. I have never seen her unresponsive before. She was red, not like super sun burned or anything but she was a little red on her face and chest area. Her legs looked normal to me, but her face and chest were pretty red.On 9/17/25 at 2:40 PM, V7 CNA said, I was only involved after they brought [R1] back inside. She was left outside by [V6], apparently, she said to set a timer and she left. I guess no one must have set a timer. [V5] saw her outside and she was unresponsive.Myself, a nurse, and another CNA did vitals. Her temperature was done initially when she came in, but I don't remember what it was. After cold compresses and water her temperature was 97 something. She drank those little cups of water, probably 3 of them. We had a fan on her too. From what I know she came inside, and the nurse was rubbing her chest, and she would wake up and then fading in and out. Usually she does go out, there was a rule, no more than 10 minutes and they set a timer. Recently, it has been more lenient with the time restriction. She regularly does go out though for short periods of time. She has no button or anything to push. She does not propel her own wheelchair.On 9/17/25 at 9:38 AM, V8 LPN (Licensed Practical Nurse) said she worked Sunday. One of the CNAs had taken one of the residents outside. She came back in and said [R1] was unresponsive. They brought her back in. I put cold compresses on her and got vitals. She was very warm to touch. Red, hot. I know they had taken her out sometime after lunch. She was coming back up from lunch and then brought her back outside. They came and got me a little after 3:00 PM, I believe. The Restorative CNA had taken her out I believe. I have never had her be unresponsive before. She can't move her own wheelchair.On 9/18/25 on 3:42 PM, V13 (R1's Physician at the Acute Care Hospital) said, [R1] came in for burn, dehydration, heat exhaustion, and the UTI was caught in the work up. She was very burned. I saw her the second day and her face and neck were very red. I could see her neck was exposed and sunburned. After the first day of IV fluid, she was much improved. She was more alert and more awake. We found the UTI during the workup and started antibiotics but her improvement within the first day tells me her symptoms on admission were from the heat and sun. Treating the UTI with antibiotics would take a couple of days for an improvement. [R1] did a couple days of IV fluid. She is doing okay now. That first day after fluids really helped.The facility's undated policy and procedure showed, Resident Outside Policy; Policy Statement: At times residents who do not wander request to be taken outside to enjoy the sun and fresh air. Some residents are in wheelchairs and cannot return to the building themselves, this requires a [NAME] eye on the resident. Procedure: 1. Resident taken outside must be checked on every 15 minutes. 2. CNA who takes resident out is responsible for every 15-minute check. 3. If CNA is not able to check on resident outside, CNA must find another CNA to check on resident. a. Verbally assigning this to another CNA b. Announce over walkie. 4. If the resident appears to be in distress, the resident is immediately brought back inside and assessed by the nurse. The Immediate Jeopardy that began on 9/14/25 was removed and the deficient practice corrected on 9/19/25 when the facility took the following actions to remove the Immediacy and correct the noncompliance. 1. An assessment form was created and immediately implemented to assess the residents' ability to safely be outside unattended. All residents have a completed assessment for going outside unattended. Newly admitted residents will have a completed assessment for going outside unattended. This assessment will be reviewed quarterly and if there is any change in condition. Audits will be completed quarterly by DON or designee. Completed 9/19/2025 2. Current policy reviewed. Input from Certified Nursing Assistants (CNAs) was collected via Survey Monkey. Policy updated with feedback from managers and CNAs. In addition to identifying safety measures and resident assessment, the policy includes timely checks on the resident and documentation on a log. A timer is placed at the door entry (Door 4) where residents go (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145495 If continuation sheet Page 4 of 5 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 09/19/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete outside. The log book is stationed at Team B nurses' station, next to Door 4. The log includes documenting time going outside, 15-minute checks, notes regarding resident, hydration offered, time coming in, and staff signature. Completed 9/19/2025 3. All managers were educated on the new policy/procedure. Managers then educated their staff. This ensured that staff were educated on the policy and procedure prior to their next shift worked. Agency: New policy & Procedure has been sent to agency organizations who will in turn disseminated to their staff. Agency staff will be educated on arrival by DON or designee. Completed 9/19/2025 4. Policy states that whoever takes the resident outside is the one responsible to ensure 15-minute check is conducted. A timer is set for 15 minutes to alert for checking on the resident outside. If the CNA is unable to check on resident, CNA must find another CNA to check on the resident. CNA must confirm with other CNA that the 15-minute check is being conducted, either verbally or over the walkie/talkie. If the CNA is unable to find another individual to do the 15-minute check, the resident is brought back in to the facility. Completed 9/19/2025 5. Weekly audits will be conducted by DON or designee. Completed 9/19/2025 6. Removal of Immediacy completion date: 9/19/2025 Event ID: Facility ID: 145495 If continuation sheet Page 5 of 5