The incident occurred on August 5 when inspectors observed Resident 33 lying in bed with gnats flying throughout her room and landing on her bed linens and wound dressing. An hour later, a wound nurse entered to perform treatment while gnats continued flying in the air and landing on the patient's gown and bandages.
When the nurse removed several layers of bandages, inspectors observed gnats inside the dressings and on the resident's open ulcerations on her right lower leg. The wound nurse acknowledged during the treatment that gnats were flying on and around the wound, telling inspectors they were "attempting to get rid of the gnats" and had submitted a work order for treatment.
Gnat strips hung in the room, but the pest problem persisted during the medical procedure. The wound nurse initially told inspectors that the Director of Nursing was also aware of the situation and had seen the gnats on the wound and bandages.
The patient suffered from pressure ulcers, paralysis following a stroke, and received hospice services. Her medical assessment from July indicated she was cognitively intact and had developed pressure ulcers upon admission to the facility.
Pest control records revealed significant gaps in treatment. On July 24, the contracted company treated fruit flies in multiple areas including the laundry room, restrooms, kitchen areas, and janitor closets. The company returned on July 30 and August 2 to address bed bugs and cockroaches.
Gnats received no treatment during either visit.
The administrator moved the resident to a different room and ordered deep cleaning of the contaminated space after inspectors documented the violations. However, the wound nurse later retracted her initial statements about observing gnats on the resident and wound, claiming inspectors had "misunderstood" her comments about the insects being present in the room, on the patient, and on the bandages.
The facility's own policy mandated maintaining "an effective pest control program so that the facility is free of pests and rodents." Yet the administrator admitted during interviews that no Performance Improvement Plan existed for gnat prevention, despite his awareness of the ongoing problem.
Weekly pest control visits had occurred, but the company "did not always treat for gnats," the administrator acknowledged. He had requested a copy of the current contract to review potential revisions, but no systematic approach to address the specific pest problem had been implemented.
The violations extended beyond pest control to basic facility maintenance throughout the first floor. Inspectors documented widespread deterioration that created an unsafe and uncomfortable environment for residents and staff.
In one room housing two residents who shared a bathroom with two others, the baseboard pulled away from the wall near the entrance. Walls showed significant marring below the chair rail, and the bathroom door base was scratched and damaged.
Another resident's room featured walls that were "marred and gouged" behind the bed. A third room showed damage to the door frame near the closet, loose baseboards in the entryway, and marred bathroom walls.
The most concerning maintenance issue involved exposed toilet bolts in a bathroom shared by multiple residents. The door frame showed marring and chipped paint, creating both safety hazards and an unprofessional appearance in areas where vulnerable residents required assistance with personal care.
A fifth room displayed similar problems with marred door frames, chipped wall paint, and deteriorating surfaces throughout the bathroom area shared by multiple residents.
The Maintenance Director confirmed during interviews that all documented damage required repair, yet the facility had failed to address these basic maintenance needs that directly affected resident safety and dignity.
Federal inspectors found no evidence that Harbor Health had developed or implemented action plans to address deficiencies cited in previous inspections. The facility showed no systematic monitoring of corrective actions, despite recurring problems with both pest control and facility maintenance.
The combination of pest infestations in patient care areas and widespread facility deterioration painted a picture of institutional neglect at Harbor Health & Rehab. Residents requiring complex medical care, including hospice services and wound treatment, faced environments that failed to meet basic standards for cleanliness and safety.
The wound care incident represented the most serious immediate threat to patient welfare. Gnats carrying bacteria and contaminants came into direct contact with open wounds during medical treatment, creating infection risks for a vulnerable hospice patient who required sterile wound care procedures.
The administrator's acknowledgment that pest control visits occurred weekly without addressing the specific gnat problem revealed a lack of systematic oversight and quality assurance. The absence of any Performance Improvement Plan demonstrated that facility leadership had not taken proactive steps to protect residents from known environmental hazards.
Harbor Health's deteriorating physical plant compounded the pest control failures. Loose baseboards, damaged walls, and exposed toilet hardware created additional sanitation challenges and safety risks throughout resident living areas.
The facility's own policies required maintaining an environment "free of pests and rodents," yet management allowed conditions to persist that directly contradicted these standards during critical patient care procedures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harbor Health & Rehab from 2024-08-09 including all violations, facility responses, and corrective action plans.