The resident, identified as #150 in inspection records, had been receiving wound treatment at East Park Care Center for approximately five months before the shocking discovery. What started as a stable diabetic foot ulcer had transformed into something an attending nurse described as "disgusting."
RN #800 told inspectors an aide had approached her that day saying the resident's wound dressing had fallen off. When she and LPN #807 went to assess the situation, they found the maggots writhing inside the open wound.
"There were approximately 20 maggots in the wound," RN #800 stated during her interview with federal inspectors on October 22. She said she "cleansed the area as much as she could" before instructing the LPN to arrange immediate hospital transport.
The maggot infestation represented the culmination of systematic care failures stretching back months. Wound NP #706, who had been treating the resident's injuries for five months before leaving her position, revealed a pattern of improper wound management that allowed the condition to spiral out of control.
"There were some incidents when the wrong dressing was applied or the wound was not padded and protected," the former wound nurse practitioner told inspectors. She confirmed the resident's heel wound had grown larger over time and was documented as deteriorating.
The wound had originally presented as a stable necrotic area on the resident's right heel, which the nurse practitioner was treating with Betadine. But at some point during treatment, the diabetic foot ulcer transformed into a pressure injury, though the nurse practitioner could not recall the exact date of this transition.
What she did remember was the decline. "Wound NP #706 stated she had noted some decline in his right heel," according to the inspection report. The wound's deteriorating condition was documented as it grew progressively larger under the facility's care.
The resident, described by staff as "very compliant with care," would even ask caregivers for additional cleanings when needed. His cooperation made the eventual maggot discovery all the more striking, suggesting the infestation occurred despite his willingness to participate in his own treatment.
Federal inspectors determined the facility had violated wound care standards, finding actual harm to the resident. The facility's own wound care policy, dated September 2021, required staff to verify physician orders before providing treatment and document all wound care procedures in the resident's medical record.
RN #800's response after discovering the maggots revealed the urgency of the situation. After cleaning the wound as thoroughly as possible, she immediately focused on getting the resident transferred to a hospital for emergency treatment. She then returned to her regular nursing duties, leaving the resident's fate in the hands of hospital physicians.
The former wound nurse practitioner's departure from the company complicated the inspection process. During her interview, she told inspectors she "was unable to recall any additional information as she was no longer employed with the company and did not have access to her notes for this resident."
This case emerged from a complaint investigation, suggesting family members or other concerned parties had raised concerns about the resident's care before the maggot discovery. The inspection was completed as part of complaint number 2642458, following an initial complaint survey conducted on October 14.
The facility policy required documentation of wound care procedures in the resident's medical record, but the systematic failures in dressing application and wound protection suggest these protocols were not consistently followed. The wrong dressings and lack of adequate padding allowed the diabetic wound to deteriorate from a stable condition to one requiring emergency intervention.
Federal regulations classify this violation as causing actual harm to few residents, but for Resident #150, the consequences were immediate and severe. The discovery of 20 moving maggots in an open wound represents one of the most disturbing care failures inspectors can document.
The resident's compliance with treatment made the deterioration particularly troubling. Staff noted he would actively request additional cleanings, demonstrating awareness of his condition and willingness to participate in proper hygiene. Yet despite his cooperation, the facility's wound care system failed him catastrophically.
After months of improper dressings and inadequate protection, a routine check on a fallen bandage revealed the extent of the facility's negligence. The maggots had found their way into living tissue, creating a medical emergency that required immediate hospital intervention and left lasting questions about how such severe neglect could occur under professional nursing care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for East Park Care Center from 2025-10-28 including all violations, facility responses, and corrective action plans.