Oak View Health: Maggots Found in Resident Wound - SC
The discovery at Oak View Health and Rehabilitation on October 3, 2024, triggered an immediate jeopardy citation — the most serious level of violation — for substandard quality of care. Inspectors reviewed photos and videos that showed "a gauze soaked with a wet brown substance and maggots in the wound on the heel of the resident, with the center of the wound dark brown and white surrounding."
The resident, identified in records as R103, had been admitted initially in June 2024 and readmitted in October with diagnoses including stage 4 pressure ulcer of right heel, osteomyelitis, and methicillin-resistant staphylococcus aureus infection.
During interviews with inspectors in February 2025, R103 said his heel wounds "were only blisters when he was admitted to the facility." He explained that maggots appeared in his left heel, though records later confirmed it was the right heel. "He is not sure how the maggots got in the wound, but he knows if a fly lands on it, it lays eggs," inspectors documented.
Licensed Practical Nurse LPN7 discovered the infestation during what she said was her first time working with the resident. She told inspectors she saw "bugs, that appeared to be maggots in the resident's wound" and took a picture of the resident's foot, sending it via text to RN3 seeking advice on treatment.
The response she received was troubling.
LPN7 said she was told "that the resident had a history of parasitic infections and to treat the wound with Dakin's and dress it as best she could and that the wound nurse, who is also the ADON would take care of it the next morning when she comes in and for her not to chart it."
There was no Dakin's solution available. LPN7 reported the incident to the night nurse when her shift ended at 7 PM, then texted the Director of Nursing around 9 PM after arriving home.
LPN7 initially saw only "about 3-5" maggots around 6 PM. She was later informed that "by the time the night nurse sent the resident out, the wound was swarming with maggots."
The night shift nurse, LPN6, told inspectors she received report about the maggots and called supervisors for guidance. She said the day shift nurse had already contacted the Assistant Director of Nursing and RN3, and "was told to only dress the wound and not to clean it or do anything else."
LPN6 said she refused to accept that directive. "Her response was that she was not going to allow that, therefore she called the DON, who informed her that she wasn't aware of the situation and advised her to call the doctor."
The physician ordered immediate transfer to the emergency room. Hospital discharge documentation from October 28, 2024, confirmed that the "89 y/o male with Hypertension and cartoid artery stenosis was sent from nursing home because the staff there noticed maggots on a right heel wound."
The facility's wound care policy, revised in January 2025, states that residents "will not develop signs and symptoms of infection, unless the resident's clinical condition makes the development unavoidable." It requires weekly wound progress reports from treatment nurses.
Physician orders from late September and early October called for cleaning the right heel with Dakin's solution and applying specialized dressings daily. Progress notes from October 3 documented that "during report nurse stated resident has maggots in right heel wound."
Communication breakdowns emerged during the inspection interviews. The Assistant Director of Nursing, who also served as the wound care nurse, told inspectors she "was not aware of maggots in R103's wound." She said staff called asking about treatment plan changes, but "no one told me about maggots."
RN3 confirmed receiving the photograph from LPN7 and forwarding it to the ADON, "who confirmed to her that she could see them in the photo." However, RN3 initially "was not able to see the maggots at first but then zoomed in and was able to see them."
The Director of Nursing said she received conflicting information, stating it was "alleged that R103 had maggots in his wound." She claimed the hospital "never verified there were any maggots in the wound," contradicting the hospital's own discharge documentation.
Licensed Practical Nurse LPN8, who worked on the unit where R103 was transferred, told inspectors the "maggots were in the wound before he came to this unit." She described the wound treatment as cleaning with hydrofera blue and border gauge, with heel boots ordered for bed use.
The facility's immediate response included auditing all wounds on October 4, 2024, providing wound care education to licensed nurses, and conducting facility-wide pest inspections. Maintenance contacted Terminix for additional preventative visits, and air curtain fans were ordered for high-traffic doors.
Beyond the maggot infestation, inspectors found multiple other violations. The facility lacked required registered nurse coverage for eight consecutive hours daily on seven different dates between November 2024 and January 2025, including Christmas Day and New Year's Day.
Medication storage violations were extensive. Inspectors found expired medications throughout the facility, including insulin that had been opened beyond its 28-day limit, blood collection tubes expired since July 2024, and various medications that had expired weeks or months earlier. In one medication cart, individual resident medications were improperly stored with stock medications.
The Director of Nursing blamed the pharmacy, saying "we received the medications after the expiration date noted on the medication cards."
Food safety violations also triggered immediate jeopardy status. Inspectors found improper food storage and inadequate sanitization in the dishwasher and three-compartment sink. The facility's acting Certified Dietary Manager lacked required certification, though enrolled in a training program expected to be completed by April 2025.
One resident received oxygen therapy without a physician's order. When questioned, RN7 acknowledged after reviewing orders that "there is no active order for oxygen. She shouldn't be on oxygen unless it was an acute situation and even then, we would still get an order."
The facility reported the maggot incident was later "self-reported and subsequently cleared without citation on 12/4/24," though federal inspectors found sufficient evidence to cite immediate jeopardy during their February 2025 inspection.
R103 told inspectors that hospital staff "flushed them out at the hospital."
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oak View Health and Rehabilitation from 2025-02-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Oak View Health And Rehabilitation in Conway, SC was cited for violations during a health inspection on February 11, 2025.
"He is not sure how the maggots got in the wound, but he knows if a fly lands on it, it lays eggs," inspectors documented.
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.