Health inspection·September 3, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to assess, monitor, and provide treatments as ordered and notify a provider of maggots for 2 of 3 residents (R1, R2) reviewed for quality of care in the sample of 3. This failure resulted in maggots in R1's foot wound. that R1 described as giving her the heeby jeebies. Using a reasonable person concept, maggots in a wound would cause a person to feel shame, embarrassment, anxiety, and uncleanliness for this profound, disturbing experience of parasites in a wound.1-R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including paraplegia, acquired absence of right leg above the knee, and pressure ulcer of left heel.R1's Minimum Data Set (MDS) dated [DATE] documented R1 was cognitively intact, ambulated via wheelchair, and had three stage 3 pressure ulcers that were present on admission.R1's Care Plan initiated 6/30/24 documents R1 has a wound.R1's Specialized Wound Management Note dated 7/14/25 documents R1 has left dorsal foot pressure ulcer (no stage listed) measuring 3.0 cm (centimeters) x 5.5 cm x 0.3 cm.R1's Progress Note by V5, Licensed Practical Nurse (LPN) on 7/19/25 at 2:05 AM documents, this nurse was completing wound dressing change, when maggots were noticed. maggots removed with normal saline and hydrogen peroxide was applied to wounds. wound were dried and wound dressings applied. (V6), PA (Physician Assistant) was notified and NNO (no new orders) were received.On 8/29/25 at 2:15 PM and 9/3/25 at 11:55 AM, V5 was unavailable by phone.On 8/29/25 at 2:05 PM, V6 was unavailable by phone.On 9/3/25 at 10:55 AM, R1 stated, I've had maggots in my wounds twice here. That (V5) didn't know how to do a dressing (correctly). I told her to cover up my toes good, but she didn't, and that's what happened. They were all over my foot and moving around. I told her to get them out of there. It gave me the heeby jeebies. R1 stated V5 removed the maggots, but did not send her to the hospital. On 9/3/25 at 9:35 AM, V7, Wound Nurse Practitioner (NP), stated she was not aware of R1 having maggots in her wound and would have expected the Facility to notify her, if that were the case. She stated R1 goes out to smoke frequently, and dressing changes can prevent maggots. The general procedure is to remove the maggots and send the resident to the hospital.2-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including quadriplegia, contracture of upper arm muscle, and acquired absence of right and left legs above the knee.R2's MDS dated [DATE] documented R2 was cognitively intact, ambulated by wheelchair, and had one stage two pressure ulcer and one stage three pressure ulcer that were present on admission.R2's Care Plan initiated 6/3/25 documents R2 was admitted with pressure ulcers. The interventions included treatments as ordered by physician.R2's Wound Assessment Report dated 8/25/25 documents R2 has a stage 2 left buttock pressure ulcer measuring 2.0 cm x 2.0 cm wide x 0.2 cm deep.R2's Physician Order dated 6/17/25 documents cleanse left buttock with normal saline or wound cleanser, apply Dakin's Solution 0.5%, then Hydrocortisone cream, then collagen, then calcium alginate, and cover with bordered foam dressing every day shift. R2's Treatment Administration Record (TAR) does not document this treatment was completed on 6/26/25, 6/27/25, 7/2/25, 7/23/25-7/26/25, 8/1/25, Residents Affected - Few Page 1 of 2 145518 145518 09/03/2025 Mascoutah Rehab and Nursing 201 South 10th Street Mascoutah, IL 62258

F 0686 Level of Harm - Actual harm Residents Affected - Few 8/2/25, or 8/6/25.R2's Wound Assessment Report dated 8/25/25 documents R2 has a stage 3 left posterior thigh pressure ulcer measuring 12.0 cm x 12.0 cm x 0.3 cm.R2's Physician Order dated 6/17/25 documents cleanse left posterior thigh with normal saline or wound cleanser, apply Dakin's Solution 0.5%, then Hydrocortisone cream, then collagen, then calcium alginate. Cover with bordered foam dressing every day shift. R2's TAR does not document this treatment was completed on 6/26/25, 6/27/25, 7/2/25, 7/23/25-6/26/25, 8/1/25, 8/2/25, 8/6/25.R2's Wound Assessment Report dated 8/25/25 documents R2 has a stage 3 right posterior thigh pressure ulcer measuring 12.0 cm x 15.0 cm x 0.3 cm.R2's Physician Order dated 6/17/25 documents cleanse right posterior thigh with normal saline or wound cleanser apply Dakin's Solution 0.5%, then Hydrocortisone cream, then collagen, then calcium alginate. Cover with bordered foam dressing every day shift. R2's TAR does not document this treatment was completed on 6/26/25, 6/27/25, 7/2/25, 7/23/25-7/26/25, 8/1/25, 8/2/25, 8/6/25.On 9/3/25 at 9:46 AM, V2, Director of Nursing (DON), stated wound treatments should be given as ordered and documented in the TAR, when given. The Facility's Wound Care Policy and Procedure revised 11/9/19 documents, Document treatment. 145518 Page 2 of 2