State records show frequent complaints under nursing home’s previous ownership

Published 12:02 am Wednesday, April 22, 2020

By Natalie Anderson

SALISBURY — In August, one resident at what’s now known as the Citadel in Salisbury nursing home went five hours without any pain medication after sustaining a bone fracture from a fall.

On Aug. 7, the resident fell around 1 a.m. and eventually received pain medication at 6 a.m. The incident was ultimately ruled a credible allegation of neglect after an investigation from a state survey and facility administrators.

In the investigation, which is detailed in inspection records of the facility on the “Nursing Home Licensure and Certification” section of the NC Department of Health and Human Services website, states the facility’s director of nursing said it was believed by a nurse on-duty that she didn’t have authorization to access pain medication for the patient. The nurse on-duty said administering pain medication before an x-ray could skew the results, according to state records. Neither the nursing director nor the administrator were called after the incident, according to the report. The patient was finally sent to the hospital at 8 a.m.

The nurse responsible for the incident was fired.

All throughout 2019 and in a recertification inspection in January, state records detail multiple citations at the facility that include failure to clean oxygen concentrator filters, failure to clean showers, food safety concerns, the mislabelling and/or storing of drugs, failure to meet residents’ preferences for dietary needs, failure to keep hospice records and failure to exercise basic hygiene practices such as hand-washing and removing soiled gloves.

On Tuesday, the Salisbury-based Wallace and Graham law firm filed a suit against Accordius Health, which manages the Citadel nursing home facility, located on Julian Road, for negligence, gross negligence, willful and wanton, and reckless conduct.

The Citadel is currently the site of an outbreak of COVID-19 with at least 96 positive cases, and at least 17 employees who have tested positive. Multiple deaths have resulted, though the exact number is still unknown.

As of Tuesday, Rowan County currently has 262 positive cases of COVID-19 from a total of 1,905 tests conducted. A total of 17 deaths have resulted from COVID-19 in the county, with 17 hospitalizations and 57 recoveries. More females, 147, have tested positive for the virus here compared to males — 115 positive cases. Individuals aged 65 and older make up the plurality of cases at 123, and 59.7 is the average age for a positive individual.

Zip code 28147 remains the biggest area of positive cases, which is where the Citadel is located.

But retired registered nurse Shari Keller, who has worked in nursing home facilities, said the Citadel’s staff is wrongfully receiving the blame for a lack of effective care that should be directed at Genesis, which owned and operated the facility until February — when Accordius Health took over. The issues made and then left behind by Genesis, she said, would take at least six months to correct. And a hit from COVID-19 will delay that improvement even further.

Keller’s father, 98, is a resident of the Citadel. She’s had family members at the facility since the mid-2000s. Since about 2017, when she began noticing “a decline in everything across the board,” she’s reported numerous grievances and reports and has “notebooks of notes” from what she’s seen at the facility.

“You would see it made no difference when you reported,” she said.

Since March 30, Keller said, she has visited her father at least once a week with a window and masks between them to protect the two from each other. Keller said since she’s been in and out of the facility at different times frequently throughout the years and, as a former nurse, she has witnessed and understands practices that family members of loved ones or the general public may not know.

Keller said “you should never see that tag” of violating patients’ rights for any facility. Noting the frequency that state inspectors were at the Citadel, she said “there’s your red flag.”

When Keller walked in the door on Feb. 1 after Accordius took over, she could notice a difference for the better. She said it was clear that “education was happening,” and that the facility was cleaner and staff friendlier.

Referring to the incident of the resident who went hours without pain medication, Keller discredited the excuse by saying, “I’ve never heard of pain medication that heals bones.” Keller said she’s familiar with the inspection reports, which are available online for public record.

On Monday, the Salisbury Post published an opinion column by Dr. John Bream, the medical director of the local Novant Health emergency department, detailing his concerns and opinions about inaction and lack of communication related to handling the outbreak from both the Citadel and the Rowan County Health Department. In the column, he noted that he felt the families deserved to know the truth about the outbreak at the facility and that he could no longer remain silent.

He also detailed caring for a patient whose family was not aware they were positive for COVID-19. While working another shift, the doctor described talking with a Citadel employee who tested positive and said she felt the facility “dropped the ball.”

“I have pressed, both in meetings and multiple emails and texts among emergency department leadership, Accordius and the Rowan County Health Department for Accordius and Rowan County to be proactive in addressing multiple shortcomings of the situation,” Bream wrote.

In a response to Bream’s comments, Rowan County Public Health Director Nina Oliver said that while county officials appreciate Bream’s passion and concern, “the frustration expressed in his letter is misdirected.”

Oliver said the health department and Novant Health responded quickly to positive case information received from the official North Carolina State Reporting System. She also said the county organized multiple daily calls with the Citadel administration and Novant.

Accordius Health did not respond by deadline Tuesday to a request from the Salisbury Post for comment on the statements Bream made in his column or the confirmed number of COVID-19 deaths of residents at the Citadel.

It was April 7 when Keller and other family members of loved ones at the Citadel began receiving a call that there was an outbreak at the facility.

Keller added that someone in Bream’s position wouldn’t be “involved in these layers going on.” For example, she said, some residents can opt to be their own responsible party. Then, the facility would not need to notify a family member. Even when a family member does call, the staff are required to ensure the resident has allowed their information to be disclosed to the concerned caller.

She added it’s important for the public to picture themselves as a nurse working in that environment and in a facility that was already short-staffed prior to the pandemic.

“I can only imagine what they’re feeling,” she said. “I want the community as a whole to realize this is a community effort. These people are under the gun, and they need to feel something other than the fact that they wish they were somewhere else.”

Keller said she’s launched an initiative on Facebook called “FOCUS Covid-19,” which stands for “Feeding Our Caregivers Under Stress.” The tagline states, “Long-term facility workers need your help,” as the group intends to focus on staff members who work at long-term facilities like nursing homes.

Before Rowan County has overcome the first, caregivers could face a second wave of positive cases.

“I do believe we haven’t hit our peak and will see a second wave. If we relax our social distancing and other protective factors, we could see a second or third phase,” Oliver said during a morning call among community leaders.

Already, she said, the entire community is not doing a good job about social distancing.

She said it’s too soon to “open back up.”

Shavonne Potts contributed to this report. 

Contact reporter Natalie Anderson at 704-797-4246.

About Natalie Anderson

Natalie Anderson covers the city of Salisbury, politics and more for the Salisbury Post. She joined the staff in January 2020 after graduating from Louisiana State University, where she was editor of The Reveille newspaper. Email her at or call her at 704-797-4246.

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