Inspection·September 11, 2025

F 0684 Level of Harm - Actual harm Residents Affected - Few Kerlix wrap) every shift (start date 7/1/25 and end date 8/4/25).R1's Treatment Administration Record/TAR, dated 8/1/25 through 8/31/25, documents an order to R1's bilateral food wounds for topical medication (Betadine) and open to air every day (start date 7/25/25 and end date 9/4/25). R1's Nursing Progress Note, dated 8/8/25 at 4:10 am, documents that R1 requires staff assistance with transfers, does not like to get out of bed, appetite poor and refused shower.On 8/8/25 at 6:00 am, V6's (Licensed Practical Nurse/Wound Nurse) Nursing Progress Note documents myiasis (maggots/larva) observed in the wound bed during treatment and located primarily in the base of the wound, within necrotic tissue. R1 was transported to the local emergency department ([NAME]).On 8/8/25 at 6:06 am, V6's (Wound Nurse) Nursing Progress Note documents R1 being transferred to the local hospital ([NAME]) by Emergency Services for evaluation due to complications related to bilateral foot wounds.R1's Nursing Note, dated 8/8/25 at 10:30 am, documents R1 being transferred from the local hospital ([NAME]) to a larger area hospital ([NAME]).R1's Nursing Note, dated 9/4/25 at 12:36 pm, documents hospital ([NAME]) report to the Facility for R1's return from the hospital back to the Facility. R1 was admitted to the larger area hospital ([NAME]) on 8/9/25 for a Urinary Tract Infection, Sepsis and Osteomyelitis. R1 underwent a Right above-the-knee amputation on 8/20/25, was placed on a feeding tube, insertion of an indwelling urinary catheter. On 9/2/25 R1 became unresponsive and a stroke alert was initiated, then R1 was recommended for Hospice services. R1's Paramedic Report/EMS, dated 8/8/25 at 7:21 am, documents that EMS was dispatched for complaints of foot ulcers with maggots. Staff (V6/LPN Wound Nurse) reported that V6 had started to change R1's foot dressings, approximately 30 minutes prior, and R1's diabetic ulcers were covered in maggots. R1 stated that R1 had the diabetic ulcers since approximately January or February (2025) and the Facility changed the dressings approximately one time a week, and the Facility did not notify R1 of the condition of R1's feet. R1 was transported to the local hospital ([NAME]).R1's local Hospital Triage notes ([NAME]) dated 8/8/25 at 6:37 am, documents R1 presented with Right Foot and Left Foot wounds and that when the Nursing Home staff attempted to redress the wounds, maggots were found in R1's Right Foot wound. Antibiotic was initiated for the infected wounds and an indwelling urinary catheter was placed. The Hospital Triage notes document that on 8/8/25 at 2:29 pm R1 was transported to a larger hospital ([NAME]) for treatment.R1's Hospital Notes ([NAME]), dated 9/2/25, document that when R1 presented to the Emergency Department for bilateral foot wounds, one of which was found to have maggots. The Hospital notes document that R1 had a new diagnoses including Right Above-the-Knee amputation.R1's Nursing Notes, dated 8/4/25, do not document V8 (Licensed Practical Nurse/LPN) applying a dry dressing to R1's Right Foot drainage.On 9/9/25 at 2:01 pm, V5 (Former Infection Preventionist) stated, (V6/Former Wound Nurse) told me that when (V5) was doing (R1's) Right Foot treatment, that (V6) found a ton of maggots in it. Apparently, the wrong treatment was also on it. (V8/Licensed Practical Nurse) did the dressing prior to (V6) doing it and put a dry dressing (Kerlix) on it because (V8) said that (R1's) Right Foot had drainage. (R1) was sent out immediately to the local hospital ([NAME]) for the maggots, and was then transported to a larger hospital ([NAME]) for admission.On 9/10/25 at 10:12 am, V6 (Former Wound Nurse/LPN) stated, I came in around 3:00 am on 8/8/25 to do an entire facility skin sweep and around 5:00 am, when I started to do the treatment on (R1's) right foot it had a dry dressing (Kerlix) wrapped around it. I knew this was the wrong treatment, because (V10/Wound Physician) had just changed the foot treatments a few days prior, on 8/4/25, to Betadine topical and leave open to air, so I was immediately concerned when I saw that. Then I began to remove the Right Foot dressing and immediately saw that the Right Foot was covered with over fifty maggots. Honestly, I had never seen that before and I kind of freaked out. I have no knowledge on treating maggots and I was not sure if we even had the right (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145719 If continuation sheet Page 2 of 3 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 145719 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Village Healthcare 2202 North Kickapoo Street Lincoln, IL 62656 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 0684 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete supplies. I tried to call (V5/Infection Preventionist) but could not get ahold of (V5), because I think(V5) was still sleeping. So I called the Physician and ended up sending (R1) out by ambulance to the hospital in [NAME]. Once (R1) got there, they sent (R1) to the big hospital in [NAME].On 9/9/25 at 1:26 pm, V10 (Wound Physician) stated, I understand that (R1) had multiple maggots in (R1's) Right Foot wound a few days after I had just seen (R1) on 8/4/25, and changed the Right Foot treatment order to Betadine and open to air because it was dry eschar at that time. I saw no signs of infection at that time. The only way the maggots would have approved is if they would have been medical maggots ordered by a physician. I did not get notified by the Facility of (R1's) Right Foot drainage and I did not order a dressing on the Right Foot for the drainage. The Facility could have called and sent me pictures or used telehealth (video calls) to notify me of the change. I cannot verify that the wound should or should not have been covered again at this point. I am not sure that (R1's) Primary Physician was notified of the change in the wound or exactly ordered the dressing. Event ID: Facility ID: 145719 If continuation sheet Page 3 of 3