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Before Citadel outbreak, nurse aides failed to wash hands, nurses failed to follow infection prevention policy

State inspectors completed an unannounced visit to Citadel Salisbury in January and noted some nurses failed to comply with proper infection control and prevention.

SALISBURY, N.C. — Just months before a 96-person COVID-19 outbreak at a Salisbury nursing home, state inspectors documented multiple employees who failed to practice proper infection control, including basic handwashing.

Inspection records reveal inspectors visited Citadel Salisbury on Julian Road, also referred to as Salisbury Center, in late January for an unannounced recertification inspection. In all, they documented 65 pages of deficiencies, including issues of infection prevention and control.

Inspectors reported they observer a nurse aide deliver meals to three different residents, uncovering breakfast, but failing to “wash her hands or use hand sanitizer,” despite positioning two of the residents in their beds and adjusting one of their linens.

"…she stated she should have washed her hands or used hand sanitizer between each resident when she passed trays and assisted resident," inspectors noted. "(She) stated she was very anxious and just forgot to wash her hands.”

Records show another nurse aid delivered breakfast to two rooms and even fed one of the residents “without washing her hands or using hand sanitizer.”

“(She) stated she was in a hurry this morning during breakfast and forgot to wash her hands or use hand sanitizer when passing out the breakfast trays,” inspectors noted.

Inspectors also documented watching a wound care nurse touch a resident’s face in “soiled gloves” and “brushed a piece of dry skin from a reddened, raised area of skin.”

“The Wound Care nurse reported she was nervous during the wound care and she had forgotten her gloves were soiled when she touched (the resident’s) face,” inspectors noted.

Records show an inspector also witnessed a registered nurse fail to use proper handwashing and infection control practices. Inspectors documented watching her use her mouth, rather than her hands, to remove the caps off of sterile syringes before flushing a catheter line with the solution.

“(The nurse) stated she was not aware that she was doing this,” inspectors noted.

Just days after the visit, Accordius Health took over ownership of the nursing home. The facility re-educated its staff and provided a corrective action plan, according to records.

The federal government gives the facility just one star out of a five-star rating, which is considered much below average. 

The Centers for Medicare and Medicaid Services fined Citadel $325,000 in August for failing to initiate proper treatment and pain relief for a resident who fell in her room, according to inspection records.

“We are more interested in and committed our center at Salisbury than ever, accept their past as a means for paving their future and are incredibly understanding of the public concern (sic),” Accordius Health Chief Operating Officer Kim Morrow said Monday. “Certainly it was not where I thought we would be just 1 short month after acquiring this center on February 1, 2020. Almost immediately we had to move into pandemic planning at the same time as we were getting to know the residents who live and staff that work there. It was toward the end first week of April when our 1st case was identified; by the next day we moved into full PPE, called all family members whose contact information we had, talked with residents and staff and worked out a plan with the Health Department to test everyone. The results were devastating; the numbers were high. I promise you that our entire team has not stopped working 24/7 on the monitoring and caring for all of our residents. The heroic work of our direct caregivers and the love they have for each and every resident at this center leaves me speechless. We are all heartbroken over the impact this virus has had on our residents and the emotional toll it is having on their family members.”

Morrow said she recently shared a letter with families of residents. She also said the state recently surveyed the facility again in April and found no deficiencies.

“It has been only 3 months since we bought this center,” Morrow said. “We own the regulatory history of Citadel Salisbury and we stand firm in our promise to improve performance, exceed service expectations and restore the hope to this community. For all of us at Accordius Health, a lifetime of perpetual dedication to change in the skilled space remains unwavering and we will be advocates for our population always.”


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