The Citadel at Salisbury, seen in this aerial photo, has had one of the largest outbreaks of coronavirus cases in the state. It also has a recent history of deficiencies on its inspections. Photo courtesy of WBTV

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Confirmed cases of COVID-19 continue to grow in nursing homes and other long-term care facilities across North Carolina.

Statewide, cases at those facilities account for nearly 18% of all laboratory-confirmed cases of the virus and more than half of the total deaths reported in the state.

COVID-19 spreads easily in congregate settings because residents live in close quarters, where social distancing is difficult. Many residents have reduced mobility and rely on staff for basic needs, such as food, hygiene and medication. 

[The latest: North Carolina coronavirus daily updates]

“From a staff-to-patient perspective, it’s awfully hard to socially distance when you’re providing hands-on care. And that has to continue,” said Adam Sholar, president and CEO of the N.C. Healthcare Facilities Association. The industry group lobbies on behalf of nursing homes in the state.

But much larger outbreaks have occurred at some nursing homes and residential care facilities while others have had no outbreaks or only very small ones.

Outbreaks can be a matter of bad luck — but lax practices, including failure to properly clean and sanitize dining and food preparation areas and equipment, clean medical equipment, store food and medicine and dispose of them when they are expired and properly dispose of infectious biowaste, can lead to the spread of infection. 

Past inspections at some of the facilities with large outbreaks include examples of these problems, reported by county and state survey teams in 2019 and 2020. 

To get a better sense of the issues found at facilities prior to the current pandemic, reporters from six newsrooms across the state reviewed the inspection reports for the nursing homes and long-term care facilities in North Carolina identified by state officials as having 50 or more confirmed cases of COVID-19 as of Friday, May 1. 

Of the 17 facilities whose inspection reports were reviewed, nine had inspections since January 2019 that found deficiencies involving injuries to residents or a failure to maintain cleanliness or take steps to control the spread of infectious disease.

The inspection reports reveal dozens of serious lapses in safety and care identified by regulators at some of the facilities now hit hardest by the coronavirus.

Many of the facilities with violations did not respond to requests for comment this week, when contacted by reporters with the collaborative. But in an interview Tuesday, Sholar said he had doubts about how relevant those violations are to an outbreak with so many unknowns. 

“To me, given the nature of the regulatory environment where deficiencies that are found, there is a plan to correct those and that’s put in place and monitored, I’d be a little hesitant to read too much into those,” he said.

However, Carole Herman, who runs the Sacramento, California-based advocacy group Foundation Aiding the Elderly, disagrees. She blames the current outbreaks of COVID-19 at facilities across the country on a history of lax regulation that has failed to ensure nursing homes are doing all they should to keep residents safe.

“I’m shocked at it but I’m not surprised,” Herman said of the toll the virus has taken on elderly nursing home residents.

Inspections find problems with disease control protocols

Inspectors cited failures to prevent and control infection, practice food service safety and adhere to flu and pneumonia vaccination protocols during multiple inspections in 2019 at Springbrook Nursing and Rehabilitation Center in Johnston County. The facility, which is licensed for 100 nursing home beds, had reported 79 cases of COVID-19 between staff and residents and 14 deaths as of Tuesday. 

Springbrook’s administrator, John Heath, did not respond to several phone messages or email requests for comment. 

One state survey of the facility in February 2019 found nurses were not handling dirty linens properly. Soiled sheets were tossed on the floor or simply carried to the laundry room, rather than being placed in plastic bags and properly disposed of. 

Following the review, Springbrook immediately “put in measures to make prompt efforts to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections,” according to state documents. 

Ten months later — four months before a COVID-19 outbreak was identified at the facility — the state reviewed records for five Springbrook residents and found the facility had not ensured they were offered pneumococcal or annual influenza vaccinations

In response to the citation, Springbrook said two residents received pneumonia vaccinations prior to their admission to the facility and were vaccinated again after the inspection. Two residents declined one or both of the immunizations. 

A new nurse had been tapped to lead infection control weeks before the inspection, documents show. She was aware that the person in the position previously hadn’t completed vaccinations as they should have and said the facility was in the process of auditing all residents’ immunization records.

The Pine Forest Rest Home in Northampton County had 27 confirmed cases of COVID-19 and one death as of Tuesday afternoon. While not one of the largest outbreaks in total volume, the percentage of residents infected drew reporters’ attention cases included 20 residents at the facility licensed for only 24. 

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Inspection reports posted by the state show inspectors found multiple issues in September, including failure to implement an “infection control policy consistent with Centers for Disease Control and Prevention guidelines to be followed, when staff were exposed to bodily fluids of a resident that posed significant risk of transmission of pathogens.”

According to the report, staff put special procedures in place for a resident with a severe colon infection but did not consistently follow them.

A housekeeper at Pine Forest told inspectors that she was advised to wear personal protective equipment when entering the resident’s room but had not been given any instructions on protocol about what to do when she entered the room and found “urine and feces all over the room when she first arrived.”

Although she used water and bleach, she had no guidance about the proper proportions she needed to disinfect the room, documents show. Other personnel apparently did not consistently handle soiled items from the resident’s room with sufficient care to prevent contamination, according to the report.

Multiple phone messages since mid-April requesting Pine Forest management comment about these issues were not returned.

Problems with cleanliness, resident safety cited at facilities hardest hit by COVID-19

Inspectors cited multiple problems during inspections of the Citadel of Salisbury nursing home in Rowan County, previously known as the Salisbury Center.

The facility, which is licensed for a total of 180 beds, currently has the most confirmed cases of COVID-19 of any long-term care facility in the state, with 154 cases among staff and residents and 17 resident deaths.

According to state records, the facility faced several deficient inspections in recent months, including in January when regulators cited multiple problems during an unannounced recertification visit. 

This included the failure to clean filters on oxygen concentrators used by five patients with serious breathing disorders. Surveyors also reported that showers were not being cleaned properly, with stained washcloths left in the shower area. 

The survey team expressed concern about the failure to properly wash and sanitize dining equipment, including a food thermometer. 

In addition, surveyors reported several residents being served food that did not meet their medically prescribed requirements or that residents could not eat because of known medical conditions. 

A survey team visiting the Salisbury Center in September 2019 about an unrelated complaint reported finding “immediate jeopardy” involving “substandard quality of care.” 

The facility “failed to initiate medical treatment and pain relief” on a resident with COPD and dementia who fell, fracturing several leg bones causing severe pain, the team reported. 

A nurse who chose not to administer pain medication after the fall claimed she thought it would interfere with X-ray results, the survey team said. Surveyors said the nurse also told them that “she was very busy that night, she had to go do something for another resident, and time had gotten away from her.” 

To correct these problems, once the resident received full treatment, the facility was required to institute additional staff training. The nurse responsible was suspended and not allowed to return to work, the team reported.

In a separate inspection, surveyors cited the Salisbury Center on Nov. 13 for multiple violations, including putting a patient with oxygenation issues on a breathing device without a physician’s authorization and despite a doctor saying she didn’t need the machine at the time. 

The Citadel of Salisbury is owned by Charlotte-based Accordius. The company did not respond to an email request Tuesday for comment on the facility’s inspection track record. Attempts to leave a message either with an employee or on a voicemail at both the nursing home and corporate office were unsuccessful.

A November 2019 inspection at Cherry Springs Village in Henderson County, which is licensed for a total of 60 beds, came in response to a complaint about bedbugs. The surveyor who completed the inspection wrote that the facility was out of compliance with sanitation rules requiring “effective measures” to keep out vermin.

“Interview with the administrator revealed a current bedbug problem has been ongoing since October of 2018,” the surveyor wrote on Nov. 22. Records indicated multiple rooms had been treated on at least two occasions for the infestation, but the surveyor observed live bedbugs. The facility agreed to pest control treatment in additional rooms, plus ongoing treatment.

The report also found that the facility was not effectively cleaning rooms, which was interfering with resolving the infestation. The surveyors described seeing 15 dead bedbugs that had not been cleaned up in one room.

An annual inspection in September cited the facility for multiple issues with cleanliness and food storage and labeling. Among other issues, an ice machine that had built up a black residue wasn’t being cleaned because different staff members thought it was someone else’s responsibility.

The latest data from the state show Cherry Springs Village has seen nine residents die from COVID-19 in the midst of its outbreak of 57 cases.

“Those individuals are being treated in isolation by health professionals, and the community is under quarantine until further notice,” James Harvey, a spokesperson for Cherry Springs Village, said in a statement last month.

Harvey emphasized the facility’s adherence to strict health guidelines from the state and the Centers for Disease Control and Prevention to prevent infections.

Asked about the facility’s recent history of deficient inspections, Harvey responded in an email, “We immediately corrected these deficiencies.” He added that previous violations were “unrelated” to  new infection control measures the facility put in place in February.

“Cherry Springs Village continues to follow strict infection control protocols, including the use of personal protective equipment when providing care, wearing masks at all times and changing clothes and following decontamination procedures each time they enter or exit the building.”

In Mecklenburg County, regulators twice cited Autumn Care of Cornelius for deficiencies since early 2019.

Since the pandemic, 17 COVID-19 deaths have been reported and the facility has reported a total of 60 laboratory-confirmed cases. State records show the nursing home is licensed for 102 beds.

According to a state inspection report, on Feb. 12 a disheveled-looking resident who was suffering from dementia had remained in a soiled adult diaper for a long period of time. In an interview with a regulator, a nursing aide said she was “overwhelmed and it was not fair to the residents,” records show.

The facility’s director of nursing stated it was unacceptable for the resident “to look the way she looked and to have been soiled for that period of time.”

A family member had also complained that the facility left the resident in bed with no pants on. 

In an earlier inspection, on April 23, 2019, a resident with dementia was observed with yellow discharge coming from his right eyelid, and a “matted discharge” from the left eyelid. He also had stubble facial hair and a stained T-shirt. A nurse’s aide said she hadn’t attempted to wash his face or shave him or change his shirt “due to the time constraints of taking care of other residents,” according to the inspection report.

Staff at Autumn Care of Cornelius responded to that report by promising to provide education to all nursing staff to ensure all residents are properly bathed and that they receive adequate hygiene care.

The nursing home’s administrator also promised to audit the bathing and grooming provided to residents over 12 weeks.

In February 2019, the federal Centers for Medicare and Medicaid Services fined the home $10,342 for deficiencies that included the center’s “lack of a complete care plan that meets all the resident’s needs.”

“The facility acts in the best interests of its residents to promote their health, safety, and welfare. The staffing levels meet or exceed the state required guidelines,” Dr. Nancy Istenes, the nursing home’s chief medical officer, said. “The level of care provided to any one resident may not accurately reflect the high quality of care the facility provides as a whole, and the number of positive outcomes encountered by residents and their families.”

Advocates, industry group respond to findings at nursing homes, long-term care facilities

Herman, the elder advocate, blamed the impact COVID-19 is having on elderly nursing homes’ residents on a history of lax care and inadequate oversight.

“My reaction is: it’s the regulators’ fault,” Herman said after being presented with a summary of the findings for this story.

Herman said that after 30 years of running a nonprofit advocating for additional regulation of nursing homes, she believes an outbreak of a deadly virus was inevitable, because facilities had not been made to adhere to more strict guidelines by state regulators prior to the pandemic.

“There’s a lack of oversight,” Herman said. “Every state has a lack of oversight.”

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“Those are our most vulnerable citizens, the most vulnerable people to get this virus and the state gets a big fat ‘F’ – all of them,” she said.

Bill Lamb, board president of the nonprofit Friends of Residents in Long Term Care based in Raleigh, said North Carolina is behind other states on standards of care, ranking 46th in average nurse staffing hours and 37th in other direct care staff hours.

“We need to do better,” Lamb said.

He acknowledged that nursing home inspection violations and data about quality and staffing are different but said they go hand-in-hand.

“Staffing and adherence to standards of care like cleanliness and infection control measures are really important,” Lamb said. “It shouldn’t take a pandemic to make us aware of this.”

AARP North Carolina’s Lisa Riegel echoed the assertions of Lamb and Herman, saying these situations further highlight the need to push for transparency across congregate care facilities so that resources can be adequately deployed.

“I think the key is sharing information and being required to communicate, because we can’t fix a problem that we don’t know about,” she said. “We can’t get more funding to address a problem if we don’t hear about it.”

Sholar, the industry group CEO, contends North Carolina’s nursing homes have worked hard to slow the spread of the virus — even when so much about it was unclear in the early stages of its spread. His group and the facilities it represents supported restrictions on visitations and followed changing guidance closely.

“We’ve done everything we can to try to stay ahead of this curve and I think by and large, our state has done that well,” he said.

The facilities with outbreaks, he said, represent a cross-section of the state.

“All of us are really looking for what is the key data point, or what is the key criterion that separates some of these things,” Sholar said. “I think unfortunately there’s a little bit of just that unknown.”

One facility owner, Lauren Ware, agreed with him.

“I think a lot of people are seeking answers like, ‘how did it happen,’” she said.

Ware, a registered nurse, is the owner of Tabor Commons in Columbus County, which saw a dramatic spike in cases last week after testing the entire facility.

Tabor Commons has had its own issues with state citations, receiving one in February for improper food handling that was later resolved.

Like other areas of the facility’s response, Ware said staff adjusted their dining practices once it became clear the virus was spreading quickly.

She attributes the outbreak at her facility to the fact employees and others who tested positive were asymptomatic — and that facilities like hers can only strongly encourage compliance with mask and isolation policies among residents.

“I think it was despite people’s best efforts,” she said of the virus’ spread at Tabor Commons.

She also attributed outbreaks at congregate care facilities to the very nature of the setting. 

“I think it’s just because we are set up to be more communal.”

This story was jointly reported and edited by Kate Martin and Frank Taylor of Carolina Public Press; Gavin Off and Ames Alexander of The Charlotte Observer; Lucille Sherman and Jordan Schrader of The News & Observer; Nick Ochsner of WBTV; Emily Featherston of WECT; and Tyler Dukes of WRAL.

NC Watchdog Reporting Network

The NC Watchdog Reporting Network is a cooperative effort of investigative journalists representing seven news organizations across North Carolina. Participants include Carolina Public Press, the Charlotte Observer, the News and Observer, WBTV, WECT, WRAL and WUNC. Email CPP's news team at info@carolinapublicpress.org to contact the NC Watchdog Reporting Network.

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