Medina Nursing Center: Maggot Wound Missed for Weeks - IL
The resident, identified in inspection records only as R2, had a long history of chronic leg wounds from lymphedema and peripheral vascular disease. Staff knew his feet and toes had been swollen. What they didn't know, or didn't act on, was that a wound had opened between his toes and gone unexamined, unreported, and untreated for weeks.
The wound care nurse, identified as V3, told inspectors she had no idea how long R2 had carried the wound or the maggots. Nobody did.
Federal inspectors from the Centers for Medicare and Medicaid Services documented the failure during a complaint inspection on May 26, 2026, and cited the facility for causing actual harm to residents.
The timeline reconstructed from inspection records is specific and difficult to read. On May 1, a registered nurse identified as V4 completed a wound assessment on R2. She noticed his left foot toes were red and swollen. She also noticed a wound on the top of his big toe. "I thought he always had that," she told inspectors. "I didn't think it was new." She said she couldn't recall whether she had looked between his toes. She did not call R2's physician or nurse practitioner.
Nine days later, on May 10, R2's nurse practitioner, identified as V5, came to assess him. R2's left lower leg and foot were wrapped in a bandage. V5 did not remove it. She told inspectors she was never informed that R2 was experiencing left foot pain or that wounds had developed on his toes. "If R2 was having increased pain to his foot," she said, "staff should have assessed his foot along with looking between his toes for a source. Any new findings should have been reported to me immediately."
She added that she had no idea how long R2 had the wounds between his toes.
On May 12 and 13, another registered nurse, identified as V7, completed R2's daily wound dressing changes. R2 complained of pain in his left foot and toes on both days. V7 told inspectors she did look between his toes as much as she could, but that it was painful when she touched them. "The skin between his toes was mushy and red," she said, "but his skin always looked like this." She did not call a physician or nurse practitioner about the pain.
May 14 was when V3, the wound care nurse, helped R2's bedside nurse change his wound dressings. R2 complained of increased pain in his left toes. V3 spread the first and second toes apart. "His toes were very swollen and red," she told inspectors. "When I spread his first and second toes apart, I saw the wound with maggots in it. We immediately called the doctor."
The facility had completed only one wound assessment on R2 between April 15 and May 13, a span of nearly four weeks.
V3 told inspectors that residents with wounds are supposed to receive a wound assessment every week, including measurements and a written description of each wound. Any new swelling, redness, or wounds are to be reported to a physician immediately. The facility's own wound care policy, dated April 2026, required documentation of open wounds upon identification and at least once weekly, with physician notification any time a wound showed signs of deterioration.
Between April 15 and May 13, R2's wound was assessed once.
The nurse practitioner, V5, told inspectors she had been actively treating cellulitis in R2's lower legs during that period. She was not aware of any wounds on his feet. R2 was sometimes noncompliant with treatment, she said, refusing to keep his feet elevated and sometimes declining medications. None of that, she made clear, changed what staff were obligated to do when they saw something wrong.
What the inspectors found was a pattern of individual nurses each observing something alarming and each deciding, separately, that it wasn't their call to make. V4 saw a wound and assumed it had always been there. V7 felt mushy, red skin and heard a man cry out in pain on two consecutive days and attributed it to his baseline condition. V5 examined a bandaged foot and left it bandaged.
Nobody called the doctor. Nobody looked between the toes.
By the time someone did, R2 had a maggot-infested wound that had been present for an unknown length of time, in a man whose vascular disease made every day of delayed treatment a compounding risk.
The inspection report does not describe R2's condition after May 14, or what treatment followed, or what he lost.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Medina Nursing Center from 2026-05-26 including all violations, facility responses, and corrective action plans.
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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 13, 2026 · Our methodology
MEDINA NURSING CENTER in DURAND, IL was cited for violations during a health inspection on May 26, 2026.
The resident, identified in inspection records only as R2, had a long history of chronic leg wounds from lymphedema and peripheral vascular disease.
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.