The resident was immediately transferred to the hospital emergency department with "many maggots" in a large right-sided temple wound. Hospital staff irrigated the wound and removed multiple fly larvae that had taken up residence in the 3.5-centimeter lesion with necrotic tissue.
Federal inspectors found the facility failed to monitor or assess the cancerous wound from February 10 until June 28, despite physician orders for treatment. The resident had been picking at the lesion throughout this period, causing it to worsen from an intact skin barrier to what hospital documentation described as a "full-blown hollow wound."
Records show the resident received Aquaphor ointment treatment for two weeks between January and February. After that treatment ended, the lesion remained untreated until June 28, when physicians finally ordered antibiotic ointment after observing the resident picking at the wound.
Staff A told inspectors the cancerous lesion was discovered during a dermatology consultation months earlier but deteriorated as the resident continued to pick at it. She acknowledged the resident had physician orders for topical treatments but confirmed no medical attention was provided to the wound for four months.
The facility's weekly skin assessments from December 13, 2024 through September 7, 2025 contained no documentation of the right temple wound. Director of Nursing Services admitted during interviews she could not provide evidence the lesion was treated or assessed during the four-month gap. She also acknowledged the weekly skin checks were not accurately completed, as staff failed to document the temple lesion entirely.
Hospital records revealed the family had declined MOHS surgery for the cancer, believing the lesion was "being managed conservatively with ointments and topical creams at the nursing home." Instead, the wound marking gradually fell away over six months, creating the hollow cavity that became infested.
Physicians had prescribed multiple treatments once monitoring resumed in late June. Orders included antibiotic ointment on June 28, followed by Imiquimod cream for basal cell carcinoma treatment on July 15, and Metronidazole gel for bacterial infection on September 4. These medications were prescribed to address the deteriorating condition that developed during the months without care.
The resident was actively picking at the wound even while in the emergency department, according to hospital documentation. Medical staff found the lesion had necrotic components and referred the patient for surgical resection and skin flap advancement by plastic surgery.
Staff A described discovering bloody drainage leaking onto the resident's face and right hand from the wound on the day she found the maggots. When she attempted to clean the area, she observed the larvae moving inside the wound cavity, prompting the immediate hospital transfer.
The inspection revealed systemic failures in wound monitoring at the facility. Weekly skin assessments that should have caught the deteriorating condition were either not performed or not documented properly. The Director of Nursing Services could not explain the four-month gap in medical attention or provide evidence of any wound assessment during that period.
Federal investigators classified the violation as causing actual harm to few residents. The facility's failure to provide necessary treatment and services resulted in a cancerous lesion becoming infested with fly larvae, requiring emergency hospitalization and surgical intervention.
The resident's condition deteriorated from a manageable skin lesion to a hollow wound requiring plastic surgery reconstruction. Hospital documentation noted the patient had initially maintained intact skin barriers before the facility's neglect allowed the wound to progress to infestation.
The maggot discovery represents the culmination of months of inadequate medical monitoring and treatment at St Antoine Residence, where a resident's cancer wound was allowed to deteriorate without proper nursing assessment or physician oversight until larvae were literally eating the infected tissue.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St Antoine Residence from 2025-09-16 including all violations, facility responses, and corrective action plans.