The insect infestation reached into the facility's medical storage room, where inspectors found small flying insects emerging from a leftover pizza box sitting on top of a filing cabinet. The pizza box sat just three feet from the residents' drink cart, which contained ice, cups, lids and straws.
Multiple residents complained about the persistent pest problem during interviews with federal inspectors in September. Residents #22 and #51 told inspectors that gnats flew around them as they tried to eat their meals and said they wished the facility had an active pest control plan.
The inspection revealed insects throughout the 13-page facility. In one resident's room, inspectors observed "small flying insects with wings that were dark in color" on the lunch tray and cups, along with "multiple other insects that were dark in color flying throughout" the room.
Resident #45's window screen failed to fit properly, leaving approximately a one-inch gap that allowed insects to enter his room. Inspectors found gnats flying around his bed during their visit on September 9. Two days later, they observed a licensed practical nurse speaking to the same resident at bedside while gnats flew around the nurse's head, forcing her to swat them away.
"Gnats and horse flies would enter his room often and he would like the window screen repaired to fit the window," the resident told inspectors.
A certified nursing assistant told inspectors that small flying insects could be seen throughout the facility, "especially in the medical storage room." When the Director of Nursing accompanied inspectors to verify the medical storage room conditions, she confirmed the presence of small flying insects around both the pizza box and the nearby drink cart.
The facility's pest control records showed treatments between June 27 and August 25, but none included resident areas. On June 27, treatment targeted fungus gnats in employee areas. July 28 treatment addressed house flies and small fruit flies in employee areas. August 25 treatments covered house flies and small flies in employee areas.
No documented treatments included the rooms where residents lived and ate their meals.
Inspectors continued observing small flying insects throughout their survey week in the conference room, residents' rooms and at nurses' stations. In one shared room, they counted three gnats on the privacy curtain and found multiple gnats flying around residents' meal trays while the residents tried to eat.
The facility's own policy, titled "Homelike Environment" and dated February 2021, states that residents should be provided with a "comfortable and homelike environment."
The insect problem prompted three separate complaint investigations, numbered 2593504, 2608577 and 2593728, according to the inspection report.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" to residents. The citation falls under federal regulations requiring nursing homes to maintain sanitary conditions and provide a homelike environment for residents.
The inspection findings paint a picture of an infestation that affected both the clinical and dining areas of the facility. While staff received pest control treatments in employee work areas, the spaces where residents spent their time eating meals and receiving medical care remained untreated.
For Resident #45, the simple request to repair his window screen represented a basic need for protection from the insects that regularly invaded his living space. His complaint about gnats and horse flies entering through the gap illustrated how the facility's maintenance failures directly impacted residents' daily comfort and quality of life.
The pizza box discovery in the medical storage room highlighted the intersection between poor housekeeping practices and pest control failures. The leftover food attracted insects that then spread throughout areas where medical supplies and resident refreshments were stored, creating potential contamination risks.
The September inspection documented a systemic problem that affected multiple residents across different areas of the facility, from individual bedrooms to shared dining spaces to clinical storage areas where medical supplies were kept alongside residents' drink service equipment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Addison Heights Health and Rehabilitation Center from 2025-09-15 including all violations, facility responses, and corrective action plans.
Additional Resources
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