Resident #1's family had to bring an ultraviolet insect trap to his room in August 2025 because of the ongoing insect problem. A nursing assistant found the trap "with insects inside" when she entered the room on August 23, the same day the resident was rushed to the hospital.
Hospital records show Resident #1 was admitted "due to generally feeling weak and the need for increased oxygen." Doctors discovered infected venous ulcers and blisters on his left leg. He was treated for sepsis related to chronic venous stasis ulcer and didn't return to White Oak Manor until September 12.
The nursing assistant who discovered the insect trap told inspectors she "observed trash in the trash can" and "tried to clean up as much as she could." Housekeeping staff had to assist with the cleanup.
Director of Nursing acknowledged seeing "small flies or gnats" in the resident's room on at least one occasion, which she attributed to "a half-eaten banana." She said environmental staff were "completing extra rounding to attempt to keep the room clean" and meal trays were "removed immediately with completion of the meal."
But the resident "never wanted to eat outside of his room and would always eat snacks in the room," creating an ongoing attraction for insects.
The Director of Housekeeping painted a more disturbing picture. She told inspectors Resident #1's room "was always cleaned twice a day and throughout the day because of trash and debris in the room." The residents would "keep dirty napkins and snack bags in the room."
"The room would smell and she had observed gnats in the room and a couple of flies," according to inspection records. When she found open food, she would "place it in a bag to try to eliminate the insects that were attracted to the area."
The Maintenance Director couldn't recall being told about flies or gnats in Resident #1's room. He told inspectors he "did not keep a log of every time an issue with insects was reported" and would "just go directly to the room and spray to take care of the concern."
He said the main pest problem at the facility was "ants not gnats or flies."
The facility contracts with a pest control company for monthly treatments. But the Pest Control Representative told inspectors the company "had no record of issues with flies or gnats from the facility."
The company's most recent visit was in September. Prior to that, they had treated the facility on August 13 for "rodent stations and in the kitchen area due to cockroaches." Their reports mentioned no flies or gnats.
During the inspection itself, investigators observed "small, winged gnats in the facility conference room" over two days.
The Administrator, who described himself as "new to the facility," said he "was not aware of a fly or gnat problem." He acknowledged that "there should be no flies or gnats in resident rooms to create a safe, comfortable environment for the residents."
He also acknowledged the gnats buzzing around the conference room during his conversation with inspectors.
The timeline raises questions about the facility's response to the insect problem. Family Member #1 felt compelled to bring an insect trap in August because of ongoing issues. The Director of Nursing knew about flies and gnats. The Director of Housekeeping was cleaning the room twice daily because of the smell and debris that attracted insects.
Yet the Maintenance Director claimed no knowledge of the problem. The pest control company had no records of treating for flies or gnats. And the Administrator was unaware of any insect issues.
State inspectors found the facility failed to provide a safe, sanitary environment free from accident hazards. The violation received a "minimal harm" rating affecting "few" residents.
Resident #1 spent three weeks in the hospital being treated for sepsis from infected leg wounds. He returned to the same facility where gnats continued flying around other rooms during the state inspection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for White Oak Manor - Charlotte from 2025-11-18 including all violations, facility responses, and corrective action plans.