WINSTON-SALEM, NC - Federal inspectors documented severe dignity violations at The Citadel at Winston Salem when they found a cognitively intact resident had been left in three soiled and urine-saturated briefs while eating breakfast, with the resident expressing feelings of being "dirty, angry and neglected."
Shocking Incontinence Care Failures Documented
The July 2024 federal inspection revealed that Resident #209, who was cognitively intact and able to communicate her needs, had put on her call light at 8:15 AM requesting to be changed. The nursing assistant told her to wait because breakfast trays were arriving. When the resident again requested care when her breakfast tray was delivered, she was told she would be changed after eating.
When inspectors observed the incontinence care that finally occurred at 11:33 AM, they documented a disturbing scene. The resident was found wearing three briefs simultaneously, with another brief laid flat underneath her. Urine and fecal matter had seeped through all three briefs, the draw sheet, cotton pad, and fitted sheet, leaving dark yellow stains on the bedding.
Most concerning was the condition of the resident's skin, where inspectors observed dried fecal matter that had adhered to her body. The resident had been left in this condition for over three hours while expected to eat her morning meal.
Multiple Staff Failures and Conflicting Accounts
The nursing assistant who finally provided care, NA #4, told inspectors that finding three briefs on a resident was "not normal practice" and estimated the resident had not been changed since the previous night shift based on the dried condition of waste materials.
When questioned, NA #8, who had answered the original call light, claimed the resident never told her she needed changing - directly contradicting the resident's account. NA #8 could not explain what service she had provided when answering the call light at 8:15 AM.
The night shift assistant, NA #9, confirmed she had changed the resident between 6:00-6:30 AM but stated she only placed one brief on the resident plus one laid flat underneath - not three briefs as discovered by inspectors.
Facility Failed to Report Neglect as Required
Beyond the dignity violations, inspectors found the facility failed to complete required reporting when the Administrator was informed of the resident's feelings of neglect. Federal regulations require nursing homes to submit an Initial Allegation Report within two hours to state regulatory agencies when neglect is suspected.
When contacted by phone six days after being notified of the incident, the Administrator confirmed she had not filed the required report and had not completed her investigation into why the resident was found in three briefs without proper care.
Additional Care Deficiencies Throughout Facility
The inspection revealed systematic failures in basic care across multiple residents:
Inadequate Personal Hygiene Care
Resident #14, who required total staff assistance for personal hygiene, was found with brown substance caked under her fingernails for multiple consecutive days. Despite receiving baths from both facility staff and hospice workers, nail care was repeatedly omitted. When observed during a bath, nursing staff failed to clean the resident's fingernails, with one assistant admitting she "became nervous and forgot" this basic hygiene step.
Medication Safety Violations
The facility exceeded the federal maximum medication error rate of 5%, recording a 6.9% error rate during inspections. Critical failures included:
- Blood pressure medication given without required vital sign checks: A nurse administered carvedilol to a resident without obtaining blood pressure readings, despite physician orders requiring vital signs with specific parameters to "hold for systolic blood pressure less than 110."
- Antifungal medication unavailable for 20 doses: A resident's prescribed miconazole powder went unavailable for nearly two weeks, with 20 missed doses documented. The facility failed to coordinate between nursing and central supply to obtain the over-the-counter medication.
Food Service and Safety Infrastructure Problems
Inspectors documented that food delivery carts were missing doors for approximately three months, causing meals to arrive lukewarm and unpalatable. Test meals of shepherd's pie and vegetables were found to be "lukewarm and bland" with vegetables that were "flavorless and not thoroughly cooked."
Safety hazards were identified throughout the facility's infrastructure, with handrails on three of four floors found loose, detached from walls, or having sharp exposed edges where end caps were missing. These conditions persisted despite staff and residents using the handrails for mobility support.
Missed Medical Appointments Impact Health Outcomes
The facility failed to ensure a resident with latent tuberculosis attended a scheduled infectious disease clinic appointment when transportation equipment malfunctioned. Despite the critical nature of the appointment, facility staff failed to reschedule before the resident was discharged to a hospital two days later.
Understanding the Medical Significance
Proper incontinence care prevents skin breakdown, urinary tract infections, and maintains basic human dignity. When residents remain in waste materials for extended periods, they face increased risks of pressure ulcers, skin infections, and psychological distress. The practice of using multiple briefs is not medically recommended and can increase skin irritation.
Medication management requires precise adherence to physician parameters, particularly for blood pressure medications. Administering carvedilol without checking blood pressure could result in dangerous drops in blood pressure, especially in elderly residents who may have fluctuating cardiovascular status.
Care Planning and Family Involvement Failures
The facility also failed to properly involve residents and families in care planning processes. One cognitively intact resident reported not being invited to participate in care plan meetings for four months, violating federal requirements for resident involvement in their own care decisions.
Social services staff acknowledged missing comprehensive care plan meetings and failing to send required notification letters to families about care conferences.
Administrative Response and Corrective Actions
Facility administrators acknowledged the violations during interviews with federal inspectors. The Director of Nursing stated that "no resident should have to eat their meal in a soiled and wet brief" and confirmed that applying multiple briefs was not facility policy.
The Administrator indicated plans to implement handrail auditing systems and Environmental Services oversight, with maintenance parts ordered following the inspection. However, the systemic nature of the violations suggests deeper organizational challenges in care oversight and staff accountability.
The inspection findings highlight fundamental failures in basic nursing home care standards, from dignified incontinence management to medication safety and family communication. These deficiencies occurred despite the facility's responsibility to provide comprehensive care to vulnerable residents who depend entirely on staff for their daily needs and medical management.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Citadel At Winston Salem from 2024-07-02 including all violations, facility responses, and corrective action plans.
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