Salisbury nursing home had chronic problems long before COVID-19 outbreak, records show
A Salisbury nursing home crippled by COVID-19 had chronic problems with cleanliness and patient care that it failed to fix for months, government records show.
State records indicate that The Citadel Salisbury, northeast of Charlotte, has been the subject of 14 inspection reports since February 2019; all but one found violations.
A new lawsuit says those deficiencies are tied to North Carolina’s worst nursing-home outbreak of COVID-19. As of Friday, state health officials report that the 160-bed facility has had 144 confirmed cases among its residents and staff. That’s 32% more than any other nursing home in the state.
Sherri Stoltzfus, The Citadel’s administrator, says 19 residents have died as of Tuesday.
The Department of Health and Human Services inspects nursing homes each year — and more frequently if it receives complaints.
As recently as February, state inspectors cited the nursing home for its failure to clean showers or properly respond to patient needs — issues raised by residents that went unaddressed for up to six months, a state report says. In August, the facility was fined more than $325,000 after it failed to report and investigate the broken leg of a resident, according to ProPublica.
Last year, state inspections also found a failure to properly store and handle food and drugs as well as violations of basic hygiene, including hand-washing and the disposal of soiled gloves. Another state inspection last year noted that a nurse was fired for slapping a resident.
Meanwhile, Medicare — the federal insurance program for seniors — ranks The Citadel Salisbury as a one-star, “much below average” facility. The program also gives the nursing home a one-star rating for the category of health inspections, and two stars — below average — for staffing and quality measures.
An April 20 story by N.C. Health News found that of the 19 nursing homes reporting COVID-19 cases at that time, 15 were rated at two stars or less. Three-quarters of the infected facilities had below-average marks for staffing, the publication said.
The Salisbury facility changed names in February when the nursing home chain Accordius Health assumed ownership.
Stoltzfus said plans to correct the existing deficiencies — including one involving infection control — had been put in place before the first resident tested positive for COVID-19 in early April. She said she does not believe any of The Citadel’s listed violations helped spread the disease to residents and staff.
The most recent state findings cast doubt on The Citadel’s ability to fix the problems, citing the nursing home’s “inability to sustain an effective Quality Assurance and Performance Improvement Program.”
Stoltzfus joined The Citadel Salisbury on Feb. 17 after serving as the administrator of an Accordius nursing home in Mooresville, which also has a one-star rating from Medicare. She told The Observer during a Tuesday interview the necessary improvements to her new facility already are underway.
“We’re still doing it. We’re all still doing it,” Stoltzfus told the Observer on Tuesday. “I still have faith that this building will turn around. There are too many people who depend on it as their home.”
The disease spreads
The Citadel had its first confirmed cases of COVID-19 on April 7. A week later after testing residents, it had 96, Stoltzfus said.
As of Tuesday, The Citadel’s sickened included 102 residents and 42 employees, Stoltzfus said. The most recent cases surfaced on April 24 when nine residents in the facility’s assisted-care wing were found to have tested positive, Stoltzfus said.
According to the lawsuit by families of two Citadel residents, the spread of disease was hastened by the facility’s chronic hygiene and patient-care problems, then by a rash of mistakes by management who then lied to patients, families and employees to hide the scope of the crisis.
Affidavits from employees say the facility banned the staff from wearing masks out of fear of panicking residents, and refused to pay for testing of residents and staff. The families’ attorneys have asked a judge to intervene and review the nursing home’s policies.
“We are concerned, based on sworn statements by multiple current and former employees, residents and and family members ... that the current management has not and is not taking appropriate measures to protect the health and safety of residents and staff,” Raleigh attorney Steve Gugenheim said in a statement released after the lawsuit was filed.
On April 15, after the appearance of COVID-19 among patients and staff, a state inspection of The Citadel’s procedures for infection control showed no violations, Accordius CEO Kim Morrow said.
“We’re not counting ourselves as a success or a win,” Morrow said. “They’ve got a long way to go toward recovery in that building. Residents’ complaints, we take very seriously.”
Stoltzfus said the facility followed early guidance from the Centers for Disease Control that masks would be more effective slowing the spread of the disease if they were worn by residents instead of staff.
“We did not tell anybody not to wear a mask,” she said, before later amending her response to say that she personally had not heard anybody say that to a staff member.
Asked why Accordius, which owns 37 nursing homes in North Carolina, did not have a policy offering testing to residents and staff, Stoltzfus replied, “I can’t answer why ... My facility is my world and my home.”
Nursing home outbreaks in NC
COVID-19 is now rampaging through U.S. nursing homes where elderly patients often with significant health issues live in tight quarters.
According to the Washington Post, the number of homes reporting cases doubled within a week, to 1 in 6 nationwide.
As of Monday, North Carolina had nearly 11,850 total confirmed cases and 422 deaths. About half of the state’s COVID-19 fatalities have occurred in long-term care facilities.
Two other Charlotte-area facilities — Five Oaks Manor Rehab of Cabarrus County and Monroe Rehab Center in Union County — are among the top 10 for nursing homes with the most COVID-19 cases in the state.
Five Oaks was ranked fifth with 87 cases and seven deaths. Monroe Rehab Center, with 66 cases and 4 deaths, was 10th.
Based on their state inspection reports, neither appears to have been cited for violations with the frequency of The Citadel Salisbury.
The three most recent inspection reports for Five Oaks Manor in Cabarrus County amounted to one-page summaries of “deficiencies corrected” or “no deficiencies found.” In half of the 10 state reports on Five Oaks dating back to 2019, no deficiencies were found.
Monroe Rehab lists six reports during the same period. A July 2019 inspection led to a DHHS order for the facility to do a better job spotting and responding to deteriorating conditions of their residents. The most recent report, in August 2019, found no deficiencies.
In November, Five Oaks did receive a 56-page report citing such deficiencies as one resident being left to undergo physical therapy in “pants wet from urination.” The staff also was cited for problems with meal deliveries to needy patients and failing to promptly stop the nightly shouting by one resident that kept his roommate awake.
‘I decided not to return’
Several of the The Citadel Salisbury’s chronic problems cited in state reports were flagged by residents.
In late January, residents told state inspectors that despite their complaints The Citadel’s showers had not been cleaned for six months, nurses had failed to respond to the residents’ call lights for three months and that the staff had failed to pass out ice water for five months.
An inspection of one shower room on Jan. 28-29 found dark black grout on floor tiles and two soiled wash cloths left strewn around. Another shower room had flakes of dried skin while the walls had “long streaks of dried white drainage,” according to the reports.
In an affidavit for the lawsuit, former resident Margaret Blackwell said “it was not uncommon to find feces and urine (in the showers) that had not been cleaned up, and there never seemed to be enough staff to take care of these incidents.”
Once the virus hit The Citadel in April, the problems multiplied, according to the lawsuit and accompanying affidavits.
Blackwell said she was among the residents sickened by COVID-19 and eventually sent to a nearby hospital last month.
“At no point before I left for good did any of the nurses or staff wear facemasks,” Blackwell said in her affidavit. Nurses went room to room to treat patients, she said, but did not change gloves.
Blackwell said she was hospitalized for eight days.
“I decided not to return to The Citadel because of (how) poorly run the facility was,” according to her affidavit. “I believe it was poor management of the facility that is responsible for me and many others having contracted COVID-19.”
Stoltzfus said her building had its first COVID-19 plan in place by early March, which she said the staff adjusted as health experts around the country learned more about the disease. She said she was caught off guard by the severity of The Citadel’s outbreak.
“It did surprise me because we had followed all the guidelines,” she said. “We did everything we were supposed to do.
“It’s been a nightmare.”
This story was originally published May 6, 2020 at 6:30 AM with the headline "Salisbury nursing home had chronic problems long before COVID-19 outbreak, records show."
