Health inspection·October 24, 2025

F 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a residents' foot was free of insects for 1 of 3 residents (R2) reviewed for foot health. Findings include: R2's Undated Face Sheet, documents she was admitted to the facility on [DATE]. No diagnosis of wounds or bugs on R2's skin, including maggots. R2's Minimum Data Set (MDS) dated [DATE] documents she is alert. R2's Care Plan, dated 10/20/2025 documents R2 has an open lesion on the foot which appears to be small crack in the skin between her 4th and 5th toe on her right foot. Goal: lesion will show improvement by decreasing in size and showing no signs and symptoms of infection by next review date. Approaches: administer dressing/treatment to address/stabilize specific wound characteristics as ordered by the physician, encourage appropriate footwear is worn at all times and encourage R2 not to walk/propel chair around barefoot or in just socks/stockings, ensure footwear for proper sizing, ensure shoes are in good condition, inspect feet during ADL (activities of daily living) care and showers/bathing, report any abnormalities to physician, keep skin clean and dry, observe lesion characteristics weekly to monitor for effectiveness of treatment, notify physician if lesion shows evidence of decline, wound physician consult as needed per physician order and monitor for signs and symptoms of infection such as pain, odor, changes in exudate (drainage) characteristics, redness, edema, or cellulitis, notify physician if observed. No documentation of maggots on R2's feet documented. R2's Progress Note, dated 10/20/2025 at 12:45 PM, documents resident seen by podiatrist this AM, new area noted to right 5th toe. Appears to be a crack in skin. New order for TAO and dry dressing daily per physician. Also, daily skin checks to be completed. POA (Power of Attorney) aware of order. RD (Registered Dietitian) updated on new area. Verified that resident has properly fitting shoes a neatly trimmed nails. On 10/23/2025 at 11:30 AM R2 sitting up in wheelchair in her room. R2 was alert and stated she had a sore on her right foot, but she laughed and stated no bugs on her feet she's aware of. R2 stated staff do the dressing on her right foot daily and she's never had bugs or maggots on her feet that she's aware of. V4, LPN entered room and removed R2 slippers and socks. There was a 2 x 2 gauze between R2's 4th and 5th toe on her right foot at that time. V4 stated R2 had no wounds and no bugs on her feet and no other residents have bugs and she does wound treatments every day and follows physician's orders. Observation of R2's feet showed a very small cut between 4th and 5th digit on right foot and no wounds or redness on either heel. R2's left foot also assessed and no wounds and no maggots or bugs on either foot at that time. V7, LPN entered R2's room and stated she is the facility's wound nurse. V7 stated she returned to work from leave on 10/21/2025 and she received report that R2 had maggots on her feet but didn't have any additional information. R7 stated she never observed maggots on R2's feet. V7 showed a small cut like wound between R2's 4th and 5th digit and stated staff are cleaning the area with normal saline then apply TAO and gauze to the area. V7 stated she doesn't have access to R2's podiatry notes because the podiatrist doesn't send them to the facility for their review. V7 stated while she was on leave V5, LPN was the acting wound nurse and floor Residents Affected - Few Page 1 of 4 145294 145294 10/24/2025 Prairie Village Healthcare Ctr 1024 West Walnut Jacksonville, IL 62650

F 0687 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nurses were responsible for administering wound treatments to residents. R2's Physician's Order Sheet (POS), dated 10/20/2025 documents a new order right 5th toe cleanse area with normal saline pat dry apply TAO and place dry gauze between 4th and 5th toe change daily and PRN once a day. R2's POS, dated 10/21/2025 documents a new order for skin assessment daily. R2's Wound Management dated 10/20/2025 at 1:38 PM documents right pinky toe, 4th toe crack in skin that measured 0.2 centimeters (CM) x 0.2 cm. Staff documented, Area noted to be a small crack in the skin between 4th and 5th toe.R2's Treatment Administration Record (TAR) dated 10/20/202 documents staff are providing skin assessments and wound treatment per physician's orders. On 10/23/2025 at 3:33 PM V5, LPN stated she works night shift at the facility and was at the facility early in the morning on 10/20/2025 when V13, Podiatrist entered to assess residents. V5 stated no staff round with V13 because he comes to the facility around 5:30 AM. V5 stated V13 reported to her that R2 had maggots in between her toes and he's never seen that before and R2 has a wound on her right foot between her 4th and 5th digit. V5 stated she assessed R2's feet as soon as V13 reported this to her. V5 stated she wiped between R2's toes and assessed maggots, V5 couldn't recall which foot had maggots but stated R2 had maggots between her toes. V5 stated she reported R2 had a newly identified wound and maggots between her toes to V1, V2 and V6. V5 stated she was very busy at that time and didn't document the assessment or removal of maggots from between R2's toes because she forgot. On 10/23/2025 at 12:30 PM V6, LPN stated she was the acting wound nurse while V7, LPN was on leave. When she got to the facility in the morning on 10/20/2025 staff (unknown name) reported to her that V13 rounded that morning and stated R2 had maggots on her foot. V6 stated her and V9, CNA/Shower Aide assessed R2's feet at that time and there were no maggots assessed. V6 stated no staff including V5 reported to her that R2 had maggots and they cleaned her feet. V6 stated she would expect staff to document R2 had maggots on her foot/feet so she could report that to R2's provider for further treatment orders. On 10/23/2025 at 1:20 PM V2, Director of Nurses (DON) stated V13 reported to a nurse that R2 had maggots on her feet but V6, LPN had assessed R2's feet the morning that V13 assessed R2's feet and there no maggots present. V2 stated she didn't assess R2's feet that day because V6 had already assessed R2's feet. V2 stated R2 didn't have maggots on her feet that day and no staff reported R2 had maggots on her feet. V2 stated if R2 had maggots on her feet she expected a nurse to assess R2's feet then document the assessment in R2's medical record. V2 stated no residents, including R2 had maggots on their feet.On 10/24/2025 at 11:54 V13, R2's Podiatrist stated he assessed R2's feet early in the morning on 10/20/2025 and he noted a family of insects on R2's right foot between her 4th and 5th toes at that time and there was a small abrasion in that space as well. V13 notified the floor nurse (name known) of the concern and the nurse entered R2's room and cleansed the area and he noted the abrasion wasn't red and no signs or symptoms of infection were present. V13 stated he told the nurse to report this to the facility's wound nurse and if the wound nurse felt it was medically necessary to notify R2's PCP (Personnel Care Provider) to see if he/she wanted to order an antibiotic or not. V13 stated he wasn't done documenting R2's progress note dated 10/20/2025 and that was why the maggots weren't documented on R2's note and he had recently put an addendum to R2's podiatry progress note, dated 10/20/2025 to include the insects were present. V13 stated he can't say what specific insects were between R2's 4th and 5th digit on her right foot because he's not an insect specialist but that they shouldn't have been present. V13 stated he expected the nurse who assessed and cleansed the insects from R2's right foot should have documented the assessment and observation in R2's nurse's notes so her medical record was accurate and up to date and she should have notified the wound nurse of the insects presence as well. R2's Podiatrist Progress Note, dated 10/20/2025 documents V13 added an addendum dated 10/24/2025 small 145294 Page 2 of 4 145294 10/24/2025 Prairie Village Healthcare Ctr 1024 West Walnut Jacksonville, IL 62650

F 0687 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few insects in webspace between 4th and 5th toes also seen by nurse, so nurse was cleaning both feet The facility's Charting and Documentation policy, revised 8/2006 documents all services provided to the resident, or any changes in the resident's medical condition shall be documented in the resident's medical record. All observations must be documented in the resident's medical record. All changes in resident's condition must be recorded which includes the date and time, name and title of who provided the care and the assessment data and/or any unusual findings obtained during the treatment, notification of physician if indicated. 145294 Page 3 of 4 145294 10/24/2025 Prairie Village Healthcare Ctr 1024 West Walnut Jacksonville, IL 62650

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to maintain a complete and accurate medical record for 1 (R2) of 3 sampled residents in review of complete and accurate medical records. Findings include: R2's Undated Face Sheet, documents she was admitted to the facility on [DATE]. No diagnosis of wounds or bugs on R2's skin, including maggots. R2's Minimum Data Set (MDS) dated [DATE] documents she is alert. On 10/24/2025 at 3:33 PM V5, LPN stated V13, Facility Podiatrist entered the facility early in the morning on 10/20/2025 and assessed residents, including R2. R2's Electronic Medical Record (EMR) dated 10/23/2025 no documentation of V13's progress notes. On 10/23/2025 at 2:20 PM V1, Administrator stated V13, Facility Podiatrist doesn't share/send his progress notes with the facility, and he never has. On 10/24/2025 at 11:54 V13, R2's Podiatrist stated he is the facility podiatrist, and sees over 25 plus patients at the facility approximately four times a year. V13 stated his office sends the facility his progress notes within 2-3 days after he assesses the residents so his progress notes should be uploaded in the residents' medical records system. V13 stated he wasn't aware the facility wasn't receiving his progress notes or that his office wasn't forwarding his progress notes to the facility. The Facility's Charting and Documentation Policy, revised 8/2006 documents all observations and services performed must be documented in the resident's clinical record. 145294 Page 4 of 4