CONWAY, SC - State health inspectors discovered serious deficiencies at Oak View Health and Rehabilitation during a February 2025 inspection, including maggot infestation in a resident's wound and widespread food safety violations that prompted immediate jeopardy findings.
Maggot Infestation in Stage 4 Pressure Ulcer
In what inspectors characterized as substandard care, an 89-year-old resident with a stage 4 pressure ulcer on his right heel developed a maggot infestation in October 2024. The resident, who had been admitted with conditions including methicillin-resistant staphylococcus aureus (MRSA) infection and osteomyelitis, was receiving regular wound care treatments three times weekly when the infestation occurred.
The facility's treatment protocol called for cleaning the wound with Dakin's solution and applying Mesalt dressings with border gauze every day shift. According to inspection records, a licensed practical nurse discovered the maggots during a routine dressing change on October 3, 2024, when approximately 3-5 maggots were initially observed in the wound.
Stage 4 pressure ulcers represent the most severe category of pressure injuries, extending through the skin and subcutaneous tissue to expose muscle, tendon, or bone. These deep wounds create an environment where tissue death and drainage can attract flies if proper wound protection is not maintained. Maggot infestations occur when flies deposit eggs in open wounds, which then hatch into larvae that feed on both dead and living tissue.
The situation deteriorated significantly between the initial discovery and when the resident was transported to the hospital several hours later. Staff who responded during the evening shift reported the wound was "swarming with maggots" by the time emergency medical services arrived. One nurse documented in progress notes: "During report nurse stated resident has maggots in right heel wound."
Communication breakdowns complicated the facility's response to the crisis. When the day shift nurse who discovered the maggots contacted supervisory staff, she received instructions to dress the wound without cleaning it and was told not to document the finding. The nurse was informed the resident had a history of "parasitic infections" and that the wound care nurse would address the situation the following morning.
However, the evening shift nurse who received the report took immediate action, contacting the physician who ordered the resident sent to the emergency room for evaluation. Hospital documentation confirmed the presence of maggots and indicated medical staff flushed them from the wound. The resident was readmitted to the facility on October 28, 2024.
The presence of maggots in wounds poses multiple health risks beyond the obvious infection concerns. While medical-grade sterile maggots are sometimes used intentionally for debridement of dead tissue, uncontrolled maggot infestations from fly contamination can cause myiasis, a parasitic condition where larvae invade living tissue. This can lead to tissue destruction, secondary bacterial infections, and sepsis in vulnerable patients with compromised immune systems.
For a resident already battling MRSA and bone infection, the additional contamination from an uncontrolled maggot infestation created serious risks. Osteomyelitis requires months of antibiotic therapy, and any additional source of infection can complicate healing and potentially spread to other parts of the body through the bloodstream.
The facility's investigation following the incident revealed that treatment administration records showed wound care had been provided according to physician orders. However, the occurrence of maggot infestation suggests either inadequate wound coverage between dressing changes or environmental contamination that allowed flies access to the wound. The resident himself stated during interviews that he believed the wounds were "only blisters" when he was first admitted to the facility.
Critical Food Safety Violations
Inspectors identified immediate jeopardy conditions in the facility's kitchen related to food safety practices that placed all residents at risk of foodborne illness. The violations centered on improper sanitization procedures in both the three-compartment sink and the mechanical dishwasher—the two primary systems for ensuring dishes, utensils, and food contact surfaces are safe for resident use.
Proper sanitization in healthcare food service requires specific procedures to eliminate harmful bacteria that can cause serious illness in elderly and immunocompromised residents. The three-compartment sink method involves washing in the first sink, rinsing in the second, and sanitizing in the third with either hot water maintained at 171°F or chemical sanitizer at approved concentrations. Mechanical dishwashers must reach and maintain specific temperatures during wash and rinse cycles, with final rinse temperatures of at least 180°F for hot water sanitization or appropriate chemical sanitizer concentrations for low-temperature machines.
The inspection documented that the facility failed to use proper sanitizer in both systems, creating conditions where disease-causing organisms could survive on plates, cups, silverware, and cooking equipment used for resident meals. This deficiency was classified as immediate jeopardy because the potential for widespread foodborne illness outbreak posed serious risk to the entire resident population.
Nursing home residents face elevated risks from foodborne pathogens due to age-related immune system decline, underlying chronic conditions, and medications that may suppress immune function. Common foodborne bacteria such as Salmonella, E. coli, Listeria, and Campylobacter can cause severe complications in this population, including dehydration, sepsis, and death. Even routine pathogens that cause mild illness in healthy adults can result in hospitalization or fatal outcomes for frail elderly residents.
The facility was notified of the immediate jeopardy determination on the date of inspection, requiring immediate corrective action to protect resident safety.
Expired and Improperly Stored Medications
A comprehensive review of medication storage areas revealed extensive problems with expired medications remaining in active use throughout the facility. Inspectors found expired items in five of six medication carts and two of four medication rooms, including critical medications, insulin products, and intravenous antibiotics.
In the fourth station medication room, inspectors documented blood collection tubes expired since July 2024, IV catheters expired in August 2024, and multiple bags of the antibiotic Ceftriaxone expired in January 2025. The facility stored expired IV antibiotics in the medication room refrigerator, with staff explaining they had "no refrigeration to send the IV bags back to pharmacy."
Multiple insulin vials posed particular concern due to the critical nature of diabetes management and the shortened stability period once these medications are opened. Inspectors found insulin products with missing or expired beyond-use dates, including several vials opened in December 2024 and January 2025 that had exceeded the manufacturer's 28-day stability period after opening.
Insulin loses potency after its beyond-use date, meaning residents could have received ineffective doses that failed to control blood sugar levels adequately. Poorly controlled diabetes increases risks for numerous complications including diabetic ketoacidosis, cardiovascular events, kidney damage, and impaired wound healing—particularly problematic for residents with pressure ulcers or other wounds.
Other expired medications included cardiovascular drugs, anticoagulants, antibiotics, antacids, and supplements. One medication cart contained a 300-tablet bottle of allergy medication expired since October 2024, and another had promethazine tablets that expired in January 2025 with 20 pills remaining in the pack.
The facility's policy clearly stated that expired medications should be immediately removed from stock and disposed of according to proper procedures, with replacement ordered from the pharmacy if a current order existed. Licensed nurses are responsible for checking expiration dates before administering medications—a fundamental component of the "seven rights" of safe medication administration.
During interviews, the Director of Nursing attributed some expired medications to a pharmacy problem, stating the facility received medications that were already expired or near expiration when delivered. However, this explanation does not address the facility's responsibility to verify medications before placing them in service and to monitor expiration dates during routine medication cart audits.
Oxygen Administered Without Physician Orders
State regulations and professional standards require that oxygen therapy be administered only under physician orders due to the medical risks associated with supplemental oxygen use. Inspectors observed one resident receiving oxygen at 3 liters per minute via nasal cannula, but review of the physician orders revealed no active order authorizing oxygen therapy.
While a provider's note from February 4, 2025 documented "O2 as needed," this order was never transcribed into the facility's official order system. The unit manager confirmed during interviews that "there is no active order for oxygen" and acknowledged that the resident should not have been receiving oxygen without proper authorization, except potentially in acute emergency situations that would still require obtaining an order.
Oxygen is classified as a medication because it requires precise dosing based on individual patient needs and carries risks when used improperly. Excessive oxygen can suppress breathing drive in patients with chronic obstructive pulmonary disease, cause oxygen toxicity affecting the lungs and nervous system, and increase fire hazards. Insufficient oxygen fails to meet the patient's medical needs and can result in hypoxemia with serious organ damage.
Additional Issues Identified
Inspectors documented that the facility failed to maintain registered nurse coverage for eight consecutive hours daily on seven separate dates between November 2024 and January 2025, violating federal staffing requirements. Staff members interviewed reported frequent staffing shortages, with unit managers and the assistant director of nursing covering floor nurse positions and occasionally working as nursing assistants when unable to obtain adequate coverage.
The facility also lacked a certified dietary manager, with the current food service director still enrolled in training expected to be completed by March or April 2025. Federal regulations require facilities to employ either a qualified dietitian or a certified dietary manager/food service manager to oversee nutrition services.
Additional medication storage violations included failure to properly refrigerate probiotics after opening as directed on the label, storage of individual residents' personal medications mixed with facility stock supplies, and inadequate dating of multi-dose vials when opened. These practices create risks for medication errors, cross-contamination, and administration of ineffective products.
The facility implemented immediate corrective measures following identification of the immediate jeopardy conditions and the earlier maggot infestation incident, including staff education, enhanced monitoring, and facility-wide audits. The maggot infestation was self-reported by the facility in October 2024 and subsequently cleared without citation in December 2024, though it remained part of the current inspection findings regarding quality of care standards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Conway Manor from 2025-02-11 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.