Troubled NC nursing home failed to protect residents from abuse, investigation finds

At a troubled Salisbury nursing home, one resident was hurt by a caregiver trying to move him. When he cried out, she put her hand over his mouth to muffle the sound.

Another resident said no one helped after she complained to staff about a resident who kept offering her money for sexual favors.

A third had to be hospitalized for infections to surgical wounds after nurses failed to change his bandages for a full week.

Those are some of the many problems state inspectors recently documented inside the Citadel Salisbury, a short-staffed nursing home with a history of serious violations.

A newly published inspection report by the state Department of Health and Human Services includes more than two dozen violations at the for-profit facility. During a two-week investigation that ended March 4, the nursing home's employees told inspectors that many of the problems happened because there were too few people on the job.

Unlike most states, North Carolina has set no minimum staffing ratios for nursing homes, an industry whose primary source of revenue is taxpayer-funded Medicaid.

One Citadel nurse aide said staffing was so "horrible" that she couldn't help residents out of bed or give them showers some days. A nursing director reported that staffing was so thin that she sometimes worked 22 hours straight - and still "things fell through the crack and she could not keep up."

The findings in the 169-page report echo much of what was revealed in "Left Alone," a recent investigation by The Charlotte Observer that documented how a shortage of caregivers inside North Carolina nursing homes is putting thousands of vulnerable residents at risk.

A data analysis by Observer reporters also found that for-profit owners tend to operate with significantly slimmer staffing and more deficiencies than nonprofits.

The Citadel Salisbury is owned by Portopiccolo, a New Jersey investment company that bought about three dozen nursing homes in North Carolina over the past six years. The large majority of its facilities here earned just one or two stars for staffing and overall performance on the federal government's five-star rating system.

A troubled history

The litany of violations documented at Citadel Salisbury are by no means the first that state inspectors have found there.

The nursing home has been hit with more than $370,000 in fines since 2020. For the past two years, the federal government has put the home on its "Special Focus" list, reserved for the nation's poorest-performing nursing homes.

In a federal class action lawsuit pending against the Citadel Salisbury, families of two residents allege that "systematic understaffing" led to residents frequently not receiving medications, showers and medical attention. Some days at the home, just three nurse aides were on duty to care for the more than 70 residents, according to the lawsuit, filed by the Wallace and Graham law firm last year.

In a court filing, Portopiccolo called the lawsuit's claim of understaffing "meritless," saying the nursing home mistakenly under-reported the hours worked by agency nurses.

Portopiccolo officials declined to comment for this story. But according to the inspection report, the nursing home told state officials it is beefing up training, conducting audits and taking other steps to address the problems discovered by regulators.

Among the violations cited in the new state report:

One resident reported that a nurse aide dug her nail into his wrist, scratching him, as she attempted to turn him over in bed. "Then she covered his mouth when he yelled out," the report states. The nursing home suspended the unnamed nurse aide, according to the report.

The nursing home also didn't conduct a required criminal background check on the nurse aide, hired through a staffing agency, before allowing her to work there, regulators said.

The nursing home failed to protect a 44-year-old female resident who complained about a male resident who offered her money for sexual favors. The woman said she first reported the man's behavior to a facility social worker in January, after he offered money to kiss her.

Staff members took no action, the woman said, and the man's harassment reportedly escalated. In late February, the woman reported that the man grabbed her jacket and offered money to perform oral sex on her.

When an inspector asked how the woman was being protected, a social worker for the nursing home said: "I check on her, I don't know how to answer that question," according to the report.

Staff members frequently failed to change dressings on surgical wounds, putting residents at risk of developing infections. A nurse aide told inspectors that she could see that the dressings on one resident's wounds sometimes weren't changed for a week.

"She stated there was a really bad odor coming from his wounds when she worked with him," the report said.

The resident was hospitalized after his wounds became infected, the report said.

The nursing home responded by saying it would educate new nurses on wound care policy and conduct audits to ensure treatments are completed as ordered.

The facility had a high rate of medication errors. In a review of medication records for three residents, inspectors found errors in more than 11% of cases, the report stated.

Adequate response?

To prevent a recurrence of such problems, the nursing home said it has begun educating employees and conducting audits on proper medication procedures, according to the report.

It's not yet clear what, if any, penalties the nursing home will face. The state DHHS said it has submitted its report to the federal Centers for Medicare and Medicaid Services, which has the power to take enforcement action and impose fines.

Some question whether fines are enough to change the behavior of substandard nursing homes.

"It is becoming more and more apparent that civil monetary penalties are largely ineffective at deterring nursing homes from engaging in conduct that poses serious risks to patient safety," said Olivia Smith, an attorney with the law firm that filed the class action suit against the Citadel Salisbury.

The Charlotte Observer wants to hear about your experiences with North Carolina nursing homes. If you've had experiences you think others should know about, please share them here.

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