Nursing home put residents in ‘immediate jeopardy’ of COVID-19, state says. 18 died.

Nursing home put residents in ‘immediate jeopardy’ of COVID-19, state says. 18 died.
Nursing home put residents in ‘immediate jeopardy’ of COVID-19, state says. 18 died. (Source: Charlotte Observer)

CHARLOTTE, N.C. (Charlotte Observer) - A Salisbury nursing home where at least 18 patients have died of COVID-19 ignored federal quarantine guidelines, failed to notify families of infections and deaths, and helped create a “widespread” health crisis that put its elderly residents in “immediate jeopardy,” a new government report says.

The report follows a month-long investigation of The Citadel Salisbury, which experienced North Carolina’s worst nursing home outbreak of the disease, by the N.C. Department of Health and Human Services. As of this week, according to state records, the Rowan County facility has had 168 confirmed cases among its residents and staff, by far the highest number in the state. At least 18 people have died.

The investigation, which started April 25 and which the report described as “unannounced,” uncovered two dozen violations of government nursing home rules before and during the COVID-19 outbreak. The report says The Citadel has since addressed the failings or has plans to do so.

Paramount among the deficiencies: a systemic failure to control infection. That led DHHS inspectors to cite The Citadel for creating the most dire threat to its residents’ health and safety found on the agency’s risk-assessment scale: a widespread pattern posing “immediate jeopardy to resident health and safety.”

Other violations included a five-day delay by the nursing home before following federal guidance on the use of face masks by residents and staff. The report describes this as “a system failure (that) had a high likelihood of affecting all residents by placing them at an increased risk of developing and transmitting COVID-19.”

Citadel Administrator Sherri Stoltzfus and Kim Morrow, Accordius’ chief operating officer, did not respond to Observer emails Thursday seeking comment. In an email to the Observer earlier this month, Stoltzfus said allegations that the nursing home or its corporate leaders worsened the spread of the disease are untrue.

“No one did anything wrong to create this,” she wrote.


Many of the failings listed in the report first surfaced in a lawsuit filed against The Citadel and its corporate owners by residents and families. In the complaint, nurses say their bosses refused to authorize testing of patients and that they were prohibited from wearing masks, allegations that The Citadel and its corporate owner, Accordius Health, had said are untrue.

Salisbury attorney Mona Lisa Wallace, who helped file the lawsuit for several residents and/or their families, said the state report corroborates the allegations of patients, families and nurses, while also exposing “the intentional and reckless practices ... which have caused so much heartbreak to so many families and our community.”

The 104-page report, released last week, says nursing home leaders broke with the Centers for Disease Control and Prevention’s requirement — and their own less restrictive policy — by failing to quarantine new residents to limit the spread of COVID-19.

Of the 12 residents who were new or readmitted after hospital visits that were cited by the report, all were immediately returned to the general nursing home population instead of being isolated for the federally mandated 14 days to see whether they were infected.

In one case, a patient who tested positive at an emergency room on April 7 with The Citadel’s first confirmed case of COVID-19 was allowed to return to the nursing home’s general population even after her test results came back, the report says.

Likewise, the failure to notify residents and families about the spread of the disease appeared chronic and widespread. State inspectors investigated nine cases in which patients were tested for COVID-19. In each instance, the nursing home failed “to promptly notify” the residents or families of the subsequent positive test results, the report says.

In a jarring example from mid-March, one family member of a Citadel resident learned that his loved one had sickened and died only after a funeral home called him, the report says.

The findings paint a critical portrait of the decisions made or not made by The Citadel’s managers, who appear at odds in the report on what should have been done and, in interviews with investigators, look to put the blame elsewhere.

In one example, The Citadel’s “infection control preventionist” told inspectors that despite adopting an Accordius-wide policy on March 11, The Citadel did no quarantining and that she had “no input in room placement decisions.” She was also “unable to say” when the staff and patients began wearing masks and other protective items.

Several nursing supervisors said they believed new and readmitted patients should have quarantined in private rooms, but Stoltzfus and the director of nursing had not followed their recommendations.

Likewise, in another interview, the facility’s health director also said he had no say in room placement, telling inspectors that The Citadel managers were following a corporate directive.

In another exchange, DHHS inspectors questioned Stoltzfus over why the Citadel adopted a corporate policy on March 11 calling for five-day quarantines for new residents when the CDC and another government regulator had recommended a two-week isolation period two days before.

Stoltzfus, according to the report, was “unable to explain.” Nor could she explain why an empty hall in the building had not been used to quarantine new, readmitted or symptomatic patients, as the regulators had also recommended, the report says.

Later, according to the report, she told the inspectors that she considered the CDC’s 14-day quarantine period “a recommendation and not a requirement,” and that she “was not aware the facility was. not in compliance.”

In a May 21 interview, however, Stoltzfus changed her answers. She said she was aware the home’s admissions policy did not comply with federal guidelines and that it should have included a 14-day quarantine from the start. She also admitted that her facility had not initially followed the April 2 recommendation by the CDC and the Centers for Medicare and Medicaid Services that all staff wear masks as should patients when they left their rooms.

Asked to explain the five-day lag time before the mask policy was put in place, Stoltzfus, according to the report, “was unable to explain.”


The Citadel, about 40 miles northeast of Charlotte, had its first confirmed case of COVID-19 on April 7. In sworn statements for the lawsuit, members of the nursing staff said patients had become sick earlier than that but that their managers had refused to test them.

Using donated kits from a local hospital and the Rowan County Health Department, the residents were tested the first time on April 10. When the results came back, 100 of The Citadel’s 124 residents at the time had tested positive, the report says.

Emergency room physician John Bream treated some of the earliest patients. In an April column for the Salisbury Post, Bream said the nursing home, Accordius Health and local health department officials had not been candid about the true scope of the emergency.

“What we have seen relating to The Citadel situation … is a blueprint for exactly what not to do in a crisis,” he wrote.

“We now know families were denied knowledge that a COVID-19 outbreak existed at The Citadel for at least six days prior to being informed of (a) quarantine. Two days elapsed between COVID-19 positive test results and communication with families. Patients died at The Citadel without family members being notified. … Employees were wrongly denied personal protective equipment. There has been no transparency.”

Accordius has acquired at least 39 nursing homes in North Carolina over the past four years. Three-quarters of them — including The Citadel — are considered below average or worse by the Centers for Medicare and Medicaid Services, The Observer has reported.

The 4-year-old chain, the creation of the Portopiccolo Group, a New York private equity group, began operating The Citadel on Feb. 1. According to the report, Stoltzfus told investigators that her team inherited a series of problems that they tried to address as they came across them.

Other than The Citadel, the only other outbreak of any size in an Accordius-owned home in North Carolina is at Pelican Health Henderson, a facility north of Durham rated average by federal regulators. There, 77 cases have been reported and 14 have died.

Two other Salisbury nursing homes also appear on the state’s list of COVID outbreaks. The N.C. State Veterans Home has reported 51 total cases and 15 deaths while Liberty Commons, as of Tuesday, has had 10 total cases and no deaths.