The resident had called her son on September 1st asking him to bring a fly swatter because there were so many flies in her room. Six days later, she was rushed back to the hospital.
Staff G, a nursing assistant who worked only two days per week, noticed something was wrong when she returned to work September 7th. "When she admitted the week before she was okay. Alert and a little confused but perky," Staff G told inspectors. "When I saw her the next Sunday, I knew something was off. She wasn't perky and there was an odor."
The resident's roommate had complained about the smell. Staff G checked to see if the woman had soiled herself. She hadn't.
"I knew something was up. I thought it was her wound. I told the nurse, and she went in and did the treatment and found maggots."
Physical therapists had been requesting bandage changes for days. Staff H, a physical therapist, saw the resident twice on September 3rd and found her heel bandages completely soaked, along with the therapeutic boots designed to protect her wounds. The smell was "very bad," she told inspectors.
When Staff H returned that afternoon, the bandages had been changed. But the problem continued.
Another physical therapist, Staff I, described treating the resident on September 4th: "Resident 1's bandages were always soaked. It was as if the nurse would change them and they immediately became soaked again." She said gauze was wrapped around dressings placed directly on the wounds. "The smell was terrible."
The facility was chronically short-staffed. On September 5th, Staff D, a registered nurse, was handling admissions when another nurse called in sick, leaving only three nurses to pass medications and complete treatments for the entire facility.
Rather than ensuring the resident's wound care was completed, Staff D took a shortcut. She signed off on all the treatments for one wing of the facility without actually performing them. "She informed the three nurses at the facility she had signed off on them so it was one less thing they had to do but they would need to pitch in together to help get the treatments completed," the inspection report states.
Staff C, a licensed practical nurse working that evening, was grateful for what he thought was help. He didn't change the resident's dressings, believing Staff D had already completed the treatments. Only later did he learn about the maggot infestation.
"When [Resident 1] first admitted there was not an odor," Staff C told inspectors weeks later. "This developed over time."
By September 6th, the day before the resident was hospitalized, conditions had become unbearable. The woman's daughter visited and brought an air freshener, applying Mentholatum ointment under her own nose because the odor was so overwhelming.
The resident herself told inspectors that staff "did not change the dressings on her feet very often" and confirmed there were flies in her room.
Staff B, the facility's director of nursing, acknowledged that residents should receive complete body assessments upon admission, including skin evaluations, to identify existing conditions and care needs. But the inspection found this basic standard had failed.
The wound care breakdown represents a cascade of neglect. Physical therapists repeatedly flagged soaked bandages and foul odors. A nursing assistant who worked just two days a week immediately recognized something was wrong. The resident's own family brought fly control supplies and had to mask the smell during visits.
Yet nursing staff responsible for daily wound care either falsified treatment records or failed to recognize the severity of an obviously deteriorating condition.
The resident spent nearly a week with an untreated, infected wound that had become so severely compromised it attracted flies and developed a maggot infestation. Federal inspectors classified the violation as causing actual harm to the resident.
The maggot discovery on September 7th came too late. The resident was hospitalized the following day, but only after enduring days of preventable suffering in a facility that had failed to provide the most basic wound care despite clear warning signs that demanded immediate medical attention.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bridge Crest Post Acute from 2025-10-27 including all violations, facility responses, and corrective action plans.