Investigation into Citadel nursing home corroborates concerns about state’s largest COVID-19 outbreak

Published 12:00 am Sunday, June 28, 2020

By Natalie Anderson

SALISBURY — On April 14, one resident of the Citadel in Salisbury was found dead around the middle of the day. Both hospice and a local funeral home were notified, but the person named the patient’s responsible party said he wasn’t notified by the facility. Instead, he found out after being contacted by the funeral home the following day.

The complaint is one of more than 20 substantiated in the state’s latest investigation of the Citadel, a nursing home on Julian Road that’s the site of the state’s largest nursing home outbreak and the cause of a plurality of COVID-19 deaths in Rowan County. The state began an unannounced inspection into the facility on April 25 and completed it May 21.

The state report says a nurse was instructed to only notify hospice and the funeral home, with the expectation that hospice would notify the responsible party — which could be a daughter, son, family member or other person responsible for a nursing home resident— of the death. Both the facility’s medical director and administrator told state investigators that it would’ve been the facility’s responsibility to notify the family of the death.

Other complaints in the state investigation report indicate the responsible parties of eight residents at the facility weren’t notified of their loved ones’ positive COVID-19 test results. One responsible party stated that he had been receiving notifications from facility before the pandemic about any changes in conditions for the resident.

In the state report, Citadel administrator Sherri Stolzfus said “for cognitively intact residents, it was the responsibility of the resident to inform their own responsible parties of the testing results.” However, Stolzfus added that she “acknowledged the facility should have followed the regulations regarding notification of both the resident and the responsible party for the significant change of positive COVID-19 results.”

The report, conducted by the North Carolina Department of Health Services Regulation, also indicates the Citadel didn’t comply with Centers for Disease Control and Prevention guidelines for mitigating the COVID-19 pandemic until April 10. That contrasts sharply with assurances to the contrary by administrators who spoke to the Post previously. At least 12 residents who had been admitted or readmitted between March 11 and April 3 were not quarantined in a designated area of the facility despite CDC’s guidance to separate new and returning residents from current residents, according to the state report.

Additionally, the state report indicates the facility failed to fully implement the CDC’s use of face masks for both staff and residents until five days after the guidance was released. The CDC recommended the use of masks on April 2, calling for the use of facemasks for patients and residents who must regularly leave the facility for care as well as all long-term care facility residents when possible.

The Citadel didn’t mandate masks until April 4 for staff and April 7 for residents. The Post first reported on the presence of the Citadel outbreak on April 9.

The state report concluded that, “this system failure occurred during the COVID-19 pandemic and had a high likelihood of affecting all residents by placing them at an increased risk of developing and transmitting COVID-19.” The state reports a total of 168 cases at the facility, with 54 being staff and 114 being residents. Rowan officials have reported 154 of those cases are among people who live in the county.

One resident, according to the state report, returned to the facility on March 12 after a hospitalization. The resident returned to a private room, wasn’t quarantined and died three days later, according to the state’s report.

In the report, an administrator said the policy for new and returning residents was for them to stay in private rooms, separate from general population halls, for five days before being moved to the general population hall. The administrator was unable to explain why the policy wasn’t followed and why it called for five days and not 14 days.

Another resident who had been readmitted was positive for COVID-19 and not under quarantine, the report states, adding the resident was not wearing a mask and was being cared for by a nursing assistant who said she also wasn’t wearing a mask.

Stoltzfus confirmed that from March 19 to April 3 the facility’s corporate policy for COVID-19 related to admissions and readmissions didn’t comply with CDC guidelines. Additionally, another hall that was open wasn’t being used for new and returning residents even though quarantined residents could have been placed there.

Part of the facility’s plan to resolve the complaints outlined in the recent state report included implementing ongoing conference calls with county health officials three times a week. County health officials advised the facility not to admit new residents until 28 days after the last positive test result, according to the report.

In late April, the county created a nursing home coordinator position to check in with local nursing homes and help prevent further spread of the virus. Some of the check-ins included calling the nursing homes to ensure they have a plan in place if there is an outbreak, make sure they are properly disinfecting the facilities and determine if they have enough personal protective equipment.

Local law firm Wallace & Graham has filed two lawsuits against the Citadel since the pandemic. The first focused on the death of a resident who had previously tested positive for COVID-19; it was dismissed “to allow the family to grieve and to get (the resident’s) estate in order.” The second seeks an injunction “to force compliance with regulations and North Carolina law.” It does not seek monetary damages. It includes 14 affidavits, including sworn statements from anonymous staff.

The firm said the 104-page state report reflects detailed insight into the “intentional and reckless practices at the Citadel Salisbury nursing home which have caused so much heartbreak to so many families and our community.”

“The report corroborates many of the statements made by brave facility nurses and staff members who spoke out in the sworn affirmations that were filed in Rowan County Superior Court on April 28, 2020 and on May 18, 2020,” Wallace and Graham said in a statement. “The report also corroborates the complaints of the many concerned family members who have loved ones at the facility to this day as well as the complaints raised by family members who have been devastated to lose their loved ones to the COVID-19 epidemic at the nursing home.”

The law firm also added that the “large, for-profit chain” owns other nursing homes in the state with similar unsafe practices. Accordius Health is the company that oversees the Citadel.

The Citadel did not immediately respond to a request for comment from the Salisbury Post. But in a previous interview, Stoltzfus, the Citadel administrator since February when Accordius Health became the new owner, said the nursing home started preparing for an outbreak a month before the first positive case. Initial preparation included designating one empty hall as a “respiratory” section, where positive residents were placed and employees could don more protective equipment than what was typically needed. Additionally, Stoltzfus said, as guidance from the CDC and other health experts changed, so did the Citadel’s guidelines.

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.

email author More by Natalie