SALISBURY, N.C. — (Warning: Story contains graphic details)

Workers at a nursing home in Salisbury, North Carolina, thought they saw a man with severe cognitive disabilities grab a mouse out of the trash and then swallow the rodent, yet they failed to immediately tell a doctor or his family, according to a newly published inspection report

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Inspectors detailed "substandard quality of care" during their recent complaint investigation at Accordius Health at Salisbury.

Their survey found the facility, located in a city northeast of Charlotte, placed a man in immediate jeopardy in August when he "ingested an unidentifiable object and the facility failed to immediately and effectively respond to the situation." The inspection report reveals the man, suffering from dementia and psychosis, also had a history of rummaging through the trash.

Through interviews with staff members, inspectors painted a detailed picture of a man failed by the people entrusted to his care. A social worker reported seeing the man with a food container in one hand and something else in his other hand before turning around and putting something in his mouth.

"The Social Worker stated Resident #1 turned back towards him and he had what looked like a black string hanging from his mouth that was approximately three to four inches long," the report says. "The Social Worker stated he could not tell what Resident #1 put in his mouth. The Social Worker stated he did not report what he saw to the Physician or the Family Member."

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The nursing home's director of nursing said she saw the man walk by with a "food container from the trash in his hand and a 2-inch-long dark-colored string hanging from his mouth," but couldn't stop him before he swallowed the string, according to the inspection report.

Inspectors documented an interview with a nurse aide who said the man spit out a "greyish-brown ball of fur with a piece of grizzle in it."

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Their complaint investigation found the facility failed to immediately alert the man's doctor and family. Instead, the inspection report reveals staff told a physician the following morning. It goes on to say they told the man's family and poison control three days after the incident.

"It just turns my stomach and gives me a sinking feeling," attorney John Hughes said.

"It's incredibly disappointing for me," attorney Olivia Smith added. "It's just a lack of basic care."

Hughes and Smith work for a Salisbury law firm with pending litigation against the nursing home's parent company Accordius Health.

"The facilities owned by this chain consistently have some of the lowest staffing numbers in the state," Hughes said.

RELATED: COVID-19 cases and deaths continue to climb in nursing homes

They said they find it especially bothersome that something so egregious harmed a fellow human this deep into the pandemic when there's already so much attention on nursing homes.

"It really makes me think: What's happening when the surveyors aren't there?" Smith said.

During the same investigation, inspectors reported they also found nursing home employees failed to tell another man's family he tested positive for COVID-19, and that they moved him to the quarantine unit. In fact, the inspection report documents an interview with the man's responsible party revealing he wasn't notified until more than seven months after the positive test.

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The latest state data from Oct. 26 show an ongoing outbreak at Accordius Health at Salisbury, resulting in four resident deaths and 41 positive resident cases. The inspection report shows only 25% of staff were vaccinated as of early September. Federal records show the vaccination rate more than doubled by early October to 58.7%.

"These kinds of issues should concern all of us," Hughes said. "It reinforces the sense that we have and that our clients have that this industry needs more regulation."

Loading ... shows the government gives the facility just a one-star rating overall.

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Accordius Health did not respond to WCNC Charlotte's multiple interview requests, but the inspection report shows the company took detailed corrective action at Accordius Health at Salisbury. The facility promised to audit current residents "to ensure that physician and the resident responsible parties have been notified of changes in condition for the last 30 days to include ingestion of unidentified objects and notification of COVID positive residents by 9/30/21," according to the inspection report.

RELATED: NC long-term care facility residents get booster shots

The nursing home also pledged that staff would be reeducated about "addressing resident safety concerns related putting unknown objects in their mouth, adequate resident supervision is being maintained, the physician/ responsible parties/ facility administration are being notified to ensure that safety measures and resident supervision are in place," the document said.

Records show on the same day inspections completed their survey, the federal government penalized Accordius Health at Salisbury $48,525.

WCNC Charlotte is always asking "where's the money?" If you need help, reach out to the Defenders team by emailing

The latest North Carolina Department of Health and Human Services data show Accordius Health at Salisbury received $10 million in Medicaid payments for institutional days during the 2021 fiscal year.

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