Inspection·December 6, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The findings include:R1's face sheet showed he was admitted to the facility 8/15/25 with diagnoses to include dementia, metabolic encephalopathy, atherosclerotic heart disease, ischemic cardiomyopathy, chronic congestive heart failure, chronic obstructive pulmonary disease, benign prostatic hyperplasia with urinary tract symptoms. R1's facility assessment dated [DATE] showed he has severe cognitive impairment and is dependent on staff for all cares.R1's care plan initiated 9/15/25 showed, [R1] is at moderate risk for skin breakdown.R1's 12/5/25 Skin/Wound/Bruise Note entered at 11:10 AM showed, . burn. 6.0 cm x 2.5 cm. Drainage: serosanguinous light. when resident was lying in bed, knee was hovering over heater next to the bed. Prevention; what actions taken to prevent from happening again: possible room rearrange to move away from heater. R1's Wound assessment dated [DATE] showed, . Left Knee (front) burn. 6.0 cm x 2.5 cm.R1's Order Summary for December 2025 showed, . Measure/Chart. left knee burn.On 12/6/25 at 8:49 AM, V4 RN (Registered Nurse) said, I had gotten called in to [R1's] room at approximately 10:45 AM because of a new skin issue on his left knee. Upon assessment, I realized it was a burn and that is when [V6 CNA (Certified Nursing Assistant] and [V7 CNA] informed me that when they went in to [R1's] room, his knee was on the heater. [R1] uses a low bed that goes all the way to the floor. I provided the medical treatment, measured it, dressed it, and I called for a manager. The wound was warm and red, at that point there was no drainage, just redness but there was skin that looked like there was a blister that had popped. [R1] didn't report any pain to that area. when palpating the area, he does flinch. He doesn't usually stay in bed for breakfast, but they said he was sleeping really good and he has been more tired than usual. V4's said the hospice company was notified of the new wound and there were no recommendations for needing treatment outside of the facility. V4 said R1 did not require treatment from an acute care setting. On 12/6/25 at 10:51 AM, V4 and this surveyor went to R1's room. R1's bed was positioned parallel to the room's heating unit under the window. There was a grated radiator heating unit down the length of the wall under the window. V4 said the mat that was on the floor now was not there previously and R1's bed was usually pushed close to the heating unit. V4 said there would usually be only a small amount of space between the heating unit and R1's bed so that the CNA could squeeze in between the bed and the heater. V4 said R1's bed is usually in the lowest position when he is in it. V4 put R1's bed into the lowest position which showed R1's knee would have been at approximately the same height as the heating grate. On 12/6/25 at 8:57 AM, V2 DON (Director of Nursing) said, . They came into my meeting and said they needed me to come and look at something. When I went into the room to access the injury, [V4 RN] had already assessed it and dressed it. I pulled his pant leg up; it was on his left knee. I removed the dressing and saw there (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145495 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 12/06/2025 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)