Federal inspectors found the widespread pest infestation during a September 23 complaint investigation. More than ten gnats were crawling on the outside of one resident's white trash can when inspectors entered his room at 12:15 pm. The resident, identified as R5, was observed in bed asleep with several gnats resting on his bed sheet above his head.
Two trash cans with lids sat near the room's entryway, with multiple gnats flying around both containers.
The maintenance director told inspectors gnats were swarming the entry way around the trash cans and inside the resident's trash can. The white trash can was observed full of trash. The maintenance director blamed certified nursing assistants for not emptying the resident's trash, saying "the gnats are in the trash due to the certified nursing assistance not emptying R5's trash."
When the resident woke up and was eating lunch at 12:48 pm, he confirmed the ongoing problem. "He has had a problem with gnats," inspectors noted.
The unit manager said she saw gnats around the resident's bed and noted a critical detail: "R5 cannot swat the gnats away."
Three minutes later, inspectors found three gnats flying around another resident's bed and bedside table. The alert resident, R6, told inspectors directly: "She has been having a problem with gnats. It's nasty to have gnats flying around."
The infestation extended beyond individual rooms into the facility's food preparation areas. During a kitchen tour at 1:06 pm, inspectors observed three to four gnats and one large mosquito flying near the handwashing sink. The dietary manager identified the insects and said this was the dish washing area, claiming "she has not seen any gnats prior to today."
A service inspection report dated September 24 contradicted the dietary manager's statement, documenting that "fruit flies were present during the time of service" in the main kitchen area. The report recommended the kitchen floor "needs to be regrouted to prevent fruit flies from breeding."
By 3:43 pm, the pest problem had contaminated the sleeping resident's food directly. Inspectors found R5 with a partially open bag of restaurant food on his bedside table. Seven or more gnats were crawling around the top, inside, and on the outside of his food bag. Three additional gnats were resting on the wall near his bedside table.
The maintenance director confirmed what inspectors observed: "There are gnats in and around R5's food bag. There are gnats on the wall."
The facility's own pest control policy, dated March 22, 2021, acknowledges the health risks posed by flying insects in nursing homes. The policy states mosquitoes "not only bite patient and cause allergic reaction at times but also carry disease like [West] Nile virus."
The policy specifically notes that "elderly patient is more susceptible to this infection when compared to younger population and have more difficulty recovering."
The document outlines basic prevention measures: "Keep trash cans lined and empty them regularly."
Yet inspectors found exactly the opposite. Overflowing trash cans attracted swarms of gnats that crawled across sleeping residents' bed sheets and contaminated their food while flying through areas where meals are prepared for the facility's entire population.
The facility failed to implement an effective pest management program, inspectors concluded. The violation affected residents who cannot defend themselves against insects crawling on their beds and food, while potentially putting all 154 residents at risk through contaminated meal preparation areas.
Federal inspectors classified the violation as having minimal harm or potential for actual harm, but noted it has the potential to affect every resident who relies on the facility's kitchen for meal preparation.
The resident who couldn't swat gnats away continued having insects crawl across his bed sheets and food bag, while the facility's dietary manager claimed she had never seen the problem before despite a service report documenting fruit flies the following day.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pearl of Hillside,the from 2025-09-25 including all violations, facility responses, and corrective action plans.