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State releases Pine Ridge nursing home report after 2 people found dead following winter storm

The report revealed a 911 call from a resident who complained about not seeing staff members for a long time during the winter storm.

RALEIGH, N.C. — A state report says a North Carolina nursing home put its residents in “immediate jeopardy” when it left just three people to take care of 98 residents during a January storm. 

The News & Observer account says the report from the state Department of Health and Human Services released Monday said police arrived at Pine Ridge Health & Rehabilitation Center on the night of Jan. 16 after receiving a 911 call from a resident who complained about not seeing staff members for a long time. Police found two residents dead and two others in critical condition inside the nursing home. 

The report said the nursing home acknowledged the problems and has taken steps to bring the facility back into compliance.

RELATED: Pine Ridge nursing home resident's daughter says her mother is off ventilator

"I wouldn't send an animal there, that animal wouldn't even get treated," Dana Barker said.

Dana Barker often found herself visiting her mother, Shirley Smith at Pine Ridge often.

"It's sad the residents there never got the help that they needed," Barker said. "I really hope that they find somebody that either shuts the place down or finds excellent care for those people that are in there because they definitely need it because they did not get it at all."

RELATED: Pine Ridge says staffing issues created by COVID and dangerous roads during a winter storm

WFMY News 2 found Pine Ridge Health & Rehabilitation Center will make some of the following changes along with others as detailed in the report:

  • Educate all facility and agency staff on the Emergency Preparedness plan.
  • Staff must also complete 10 quizzes on Inclement Weather Emergency Preparedness. Any staff members who do not pass the quiz after three attempts will no longer be allowed to work until successful completion.
  • An Emergency Preparedness Plan exercise will be conducted with all staff quarterly.
  • The Mobile Director of Nursing, Director of Nursing, treatment nurse, or Clinical Support will complete audits to ensure residents are being treated with dignity and respect to include providing timely incontinent care, 10 audits will be completed weekly x 8 weeks and documented.
  • The Mobile Director of Nursing, Director of Nursing, or Clinical Support Staff will ensure all newly hired nurses and newly scheduled agency nurses will complete the in-service during orientation.
  • The Director of Nursing will make wound rounds with the treatment nurse to identify any signs and symptoms of wound infections. The rounds will be completed weekly x 8 weeks utilizing a Wound Audit Tool.
  • Nursing, Director of Nursing, or clinical support staff will assess residents for signs and symptoms of changes in condition to include new or worsening pain and/or gait weekly x 8 weeks.
  • The Mobile Director of Nursing, Director of Nursing, or clinical support will check the Medication Administration records of all residents with newly ordered antibiotics to ensure the medication was started when it was ordered.
  • The Mobile Director of Nursing, Director of Nursing, treatment nurse, Nursing Home Administrator, or Clinical Support Staff will make rounds to ensure basic housekeeping is completed to maintain a clean, sanitary, and orderly environment. The rounds will be made weekly x 8 weeks utilizing an environmental rounds audit tool.
  • The Mobile Director of Nursing, Director of Nursing, or clinical support staff will complete head-to-toe assessments of residents weekly.
  • Audits will include also include monitoring of medication administration, treatments, resident care observations, and conducting interviews with alert and oriented residents regarding providing basic goods and services.
  • The Interim Administrator, Human Resource Support Staff, and/or the Interim Director of Nursing will conduct staffing meetings to ensure there is enough staff, on each shift, in each department to include dietary.

Pine Ridge Health & Rehabilitation Center released the following statement after the state's report: 

"The COVID-19 pandemic created unprecedented disruptions to the nation’s skilled nursing industry. Earlier this year, the rampant spread of the Omicron variant caused significant staffing shortages despite a high vaccination rate among staff members. Pine Ridge Health and Rehabilitation Center experienced a perfect storm of challenges one evening in January due to severe winter weather, the peak of COVID-positive cases in North Carolina, and an increased reliance on contract agency staff.

“Pine Ridge has been working diligently to address issues that occurred on that day. We take the state's concerns very seriously and are responding to areas identified by regulators. We are working diligently to take meaningful steps to ensure all residents are receiving the medical care and support they need. We remain focused on the safety and wellbeing of our residents and staff. We are also grateful as Pine Ridge has not had any positive employee cases since early February.”

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