Health inspection·September 11, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 protect a wound from insect contamination and failed to provide appropriate physician ordered wound care leading to a decline in the Resident's physical well-being for one of three Residents (R1) reviewed in sample of five. This failure resulted in R1 requiring emergent transport to the local hospital and hospitalization. Findings include:The Facility Pressure/Skin Breakdown-Clinical Protocol Policy, reviewed 1/2025, documents: document the individual's significant risk factors; nurse must document/report a full assessment of skin condition; identify factors contributing or predisposing Residents for skin breakdown such as co-morbidities; document signs/symptoms of infection, skin condition assessment and the impact of co-morbid conditions on wound healing; and the physician will authorize pertinent orders related to wound treatments.The Facility Resident Rights for People in Long-Term Care Facilities, dated 11/2018, documents: the Facility must provide services to keep your physical and mental health, at their highest practical levels; and the Facility must be safe, clean, comfortable and homelike.The Facility Licensed Practical Nurse/LPN Job Description, undated, documents: to provide nursing care to Residents under the supervision of a Registered Nurse/RN and in accordance with federal, state and Facility standards; responsible for administering medications, performing treatments, monitoring Resident's health status and supporting the overall care plan to promote optimal health outcomes; administer treatments as prescribed in accordance with Facility policies and state regulations; monitor Resident's health status, observe for changes in condition and promptly report finding to the Registered Nurse or Physician; follow infection prevention and control procedures; maintain a safe environment for Residents; and comply with all state, federal and Facility regulations.R1's Physician Order Report, dated 8/1/25 through 8/31/25, documents diagnoses including Chronic Osteomyelitis, Anxiety, Anemia, Type Two Diabetes Mellitus with other skin complications, Atherosclerotic Heart Disease, Chronic combined Systolic and Diastolic (Congestive) Heart Failure, Alcohol dependence with withdrawal, Hypertension and Hyperlipidemia. The Physician Order Report documents Physician orders for: arterial ultrasound to bilateral feet for non-healing wounds (dated 7/24/25); Enhanced Barrier Precaution (dated 7/23/25); Left Foot and Right Foot cleanse with wound cleanser, dry well, apply skin barrier to necrotic areas, place topical medication (Calcium Alginate) to open area on Left Posterior Ankle and Right Medical Second Toe and Great Toe, and cover with dry dressing (Army Battle Dressing/ABD and Kerlix) every day (start date 7/1/25 and end date 8/4/25); and Bilateral Foot wounds topical medication (betadine) and open to air every day (start date 7/25/25 and end date 9/4/25). The Physician Order Report does not document a dry dressing order for 8/7/25 or 8/8/25.R1's Treatment Administration Record/TAR, dated 8/1/25 through 8/31/25, documents an order to R1's Right Foot and Left Foot to cleanse area with wound cleanser, dry well, apply skin barrier to necrotic areas, place topical medication (Calcium Alginate) on open area between right medial second toe and great toe and Left Posterior Ankle) and cover with dry dressing (ABD and Residents Affected - Few Page 1 of 3 145719 145719 09/11/2025 Lincoln Village Healthcare 2202 North Kickapoo Street Lincoln, IL 62656

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 145719 Page 2 of 3 145719 09/11/2025 Lincoln Village Healthcare 2202 North Kickapoo Street Lincoln, IL 62656

F 0684 Level of Harm - Actual harm Residents Affected - Few 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. 145719 Page 3 of 3