Lincoln Village Healthcare: Maggot Wound Failure - IL
The federal inspection, completed September 11, 2025, cited the facility for causing actual harm to at least one resident. What inspectors documented was a breakdown that unfolded in stages, each one a point where someone could have made a call and didn't.
The wound physician, identified in the report as V10, had last seen the resident, identified as R1, on August 4, 2025. At that visit, he changed the treatment order for R1's right foot. The wound was dry eschar, he said. He saw no signs of infection. He ordered Betadine and left the foot open to air.
Days later, there were maggots.
"The only way the maggots would have appeared is if they would have been medical maggots ordered by a physician," V10 told inspectors on September 9. He had not ordered medical maggots. He had not ordered anything for the wound after August 4, because nobody told him anything had changed.
Between that August visit and the discovery of the maggots, R1's wound had begun draining. The facility placed a dressing on the foot. That was a change from what V10 had ordered, which was no dressing. V10 said he was never notified about the drainage, never asked whether a dressing was appropriate, and never sent photographs or contacted through telehealth, both of which he described as options the facility had available.
"The facility could have called and sent me pictures or used telehealth to notify me of the change," he said. "I cannot verify that the wound should or should not have been covered again at this point."
He also wasn't certain R1's primary physician had been told about the change, or who had actually authorized putting the dressing back on. "I am not sure that R1's primary physician was notified of the change in the wound or exactly ordered the dressing," he said.
When the maggots were discovered, a staff member tried to reach V5, the facility's infection preventionist. The call didn't go through. According to the inspection report, the staff member believed V5 was still asleep.
So they called the physician instead and sent R1 out by ambulance. The first hospital transferred R1 to a larger facility.
That sequence — maggots found, infection preventionist unreachable, ambulance called, two hospitals — was the end result of a wound that a physician had checked five weeks earlier and found dry and uninfected, and that apparently received no physician oversight again until it required emergency transport.
The inspection report does not say how long the maggots had been present before they were found. It does not describe R1's underlying conditions beyond the wound on the right foot. It does not say whether R1 recovered, or what the larger hospital found, or what treatment followed.
What it does say is that the wound physician learned about the maggots not from the facility, but from inspectors. His account of events, given on September 9, is the clearest description in the record of what went wrong: a wound changed, a dressing was applied without his knowledge, drainage went unreported, and a resident ended up in an ambulance while the infection preventionist's phone rang unanswered.
"I did not get notified by the facility of R1's right foot drainage," V10 said, "and I did not order a dressing on the right foot for the drainage."
The violation was tagged at the level of actual harm.
R1's condition after leaving Lincoln Village Healthcare is not documented in the inspection record.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lincoln Village Healthcare from 2025-09-11 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: September 21, 2026 · Our methodology
LINCOLN VILLAGE HEALTHCARE in LINCOLN, IL was cited for violations during a health inspection on September 11, 2025.
The federal inspection, completed September 11, 2025, cited the facility for causing actual harm to at least one resident.
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.