Cherryville nursing home cited for neglect, call bell problems after state investigation

Story by Nate Morabito

Failures by Somerset Court of Cherryville resulted in the "serious neglect" of one woman and left residents without a working call bell system for an entire week, which "was detrimental to the health and safety of all the residents," newly released investigations by the North Carolina Department of Health and Human Services reveal.

The state's findings confirm what a WCNC Charlotte investigation first revealed earlier this year and followed WCNC Charlotte's reporting.

Freda failed

Investigators found Somerset Court of Cherryville's actions "unnecessarily" kept Freda Reynolds in the hospital much longer than required. As WCNC Charlotte reported in March, the facility refused to take back the outspoken resident council president, who previously filed formal complaints with regulators.

"My respect and dignity have been splattered," she told WCNC Charlotte.

Her family called it retaliation.

"I think that they definitely did not like that she spoke her mind," Freda's daughter Carrie Reynolds said at the time. "It's called dumping."

Reynolds, hospitalized in January, ended up spending 53 days in the hospital, even though the hospital's therapy department and her cardiologist cleared her to return to Somerset Court of Cherryville much sooner. The facility insisted it could no longer meet her needs and in the process, failed to follow the rules by never providing her with formal discharge paperwork and leaving her without an option to appeal.

In response to WCNC Charlotte's questions, the state opened an investigation. Shortly after, Reynolds found a new home.

NCDHHS' subsequent Corrective Action Report classified the failure as a Type A1 Violation, which is defined as "a violation by a facility of applicable laws and regulations governing a facility which results in death or serious physical harm, abuse, neglect, or exploitation of a resident."

Documents show the state plans to recommend some type of administrative penalty as a result. It's unclear how much, but state law suggests the fine could be anywhere from $1,000 to $20,000.

"No administrative penalties have been imposed yet against Somerset Court of Cherryville for the Type A1 violation," NCDHHS Press Assistant Summer Tonizzo told WCNC Charlotte. "When a Type A1 violation is cited, there are statutorily mandated procedures DHSR must follow before a penalty can be imposed. This includes the opportunity for the facility to request Informal Dispute Resolution (IDR) in accordance with G.S. 131D-2.11 and the opportunity for the facility to submit evidence of training to be considered in lieu of some or all of the penalty in accordance with G.S. 131D-34."

Linda Jay

The state opened another investigation after a fired Somerset Court of Cherryville employee raised concerns about the facility. In an interview with WCNC Charlotte, Stacy Reeves documented concerns inside this facility, including problems with call bells.

"I just want them taken care of," Reeves said of the people who lived there.

Residents like Barbara Estes said the emergency system was down when Linda Jay died in October after choking on her dinner.

"Our call bells had been turned off Wednesday of that week," Estes said at the time. "I seen (Linda Jay) grabbing her throat and running. She tried her best to get up there and get help."

After WCNC Charlotte exposed those details, Jay's daughter started asking questions of her own and the state began investigating.

"They failed her miserably," Shelley Dorton said of her mom's care. "It breaks my heart. We need to do better."

The state's investigation found the call bell system continued to be a problem three months after Linda Jay died.

"The facility failed to ensure the call bell system was working properly from 1/15/25-1/22/25," the state's investigation recently found. "Failing to have a working call bell system for seven days could result in the residents not receiving appropriate assistance with their care needs and hinder the residents' ability to evacuate the facility in the case of an emergency. This failure was detrimental to the health and safety of all the residents."

Somerset Court of Cherryville response

Records show, in an interview with investigators in March, the facility's administrator told investigators the call bell system was working properly at that point with no issues. Meanwhile, in Reynolds' case, the administrator told the state she intended to deliver the hospitalized woman a discharge notice early on, "but due to an emergency" was unable to do so and never "felt the need" to follow back up" since so much time had passed."

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Cherryville nursing home cited for neglect, call bell problems after state investigation

State investigation underway at southeast Iowa nursing home

by Nik Todorovich

SIGOURNEY, Iowa — Iowa state officials are looking into horrifying allegations about the treatment of two residents at a southeast Iowa nursing home.

In November 2022, a female resident was complaining of a headache. Her headache then turned into a migraine, which then turned into a stroke.

The resident complained about the pain to Aimee K. Crow, who is a nursing administrator at Windsor Place Nursing Home in Sigourney, Iowa.

The Iowa Department of Inspections and Appeals (DIA) is conducting investigations and officials have released 72 pages of legal paperwork detailing the allegations. The paperwork can be found HERE and HERE.

The files suggest that Crow didn't do enough to help the resident while she was struggling.

The state findings say at, "around 6:20 a.m. [on November 30, 2022] staff A checked on Resident #1. Resident #1 was soaked in urine from her shoulders to her knees."

One staff member told state investigators that it was obvious the resident suffered a stroke.

The staff member stated, "on Monday, 11/28/22, Resident #1 was up, independent, and in the dining room talking and normal, and by Wednesday, 11/30/22 she was a vegetable."

This wasn't the only incident that has been reported at the nursing home.

A male resident was kicked out of the home because he didn't accept a roommate.

He told investigators that he was originally promised a room to himself, but when that didn't pan out, a disagreement with Crow came up.

Iowa DIA findings say, "Resident #4 stated he called his nephew and got a ride to his ex-wife's home. That evening he fell down her steps and was taken by ambulance to the hospital."

The Keokuk Sheriff's Department was called to assist on the issue and a sheriff's deputy stated, "he did not feel it was right that a facility could force a resident onto the streets with no place to go."

Iowa Attorney General Brenna Bird acknowledges that the treatment some nursing care residents receive is an issue.

"It is so important that we protect our dependent adults from abuse," Bird said. "And we see that all over Iowa, dependent adult abuse. Whether it's financial or physical it is so important that we enforce those laws and keep people safe."

KTVO has reached out to Keokuk County Attorney Amber Thompson for any new updates, but her office said they can't comment due to a pending investigation.

The state paperwork doesn't say what condition the female resident who suffered the stroke is in now. After her stroke, she went into a vegetative state, but there were no other updates.

The male resident who was kicked out of the facility and ended up getting hospitalized after a fall was returned to the nursing home.

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State investigation underway at southeast Iowa nursing home

Pueblo assisted living home put residents in danger, loses license after state investigation

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PUEBLO, Colo. - UPDATE:

It is still unclear who is looking after the residents still at the Johnson Home assisted living facility. The Department of Health and Environment are not aware of who is looking after the residents who elected to remain after the license was suspended earlier this month.

Pueblo County had some Medicaid customers living at the facility and the county worked in a support role to make sure those customers were relocated.

The Pueblo County Adult Protective Services did not return any of KRDO's inquiries.

The Pueblo Department is no stranger to the assisted living facility on the 400 block of W 13th street. Since the beginning of 2017, officers have been called out to the building 523 times.

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An assisted living nursing home in Pueblo has temporarily lost its license to operate after a state investigation found that staff and administrators deliberately violated state regulations and put elderly residents in danger.

The Johnson Home assisted living facility has been operating since 2012. Earlier this month, the Colorado Department of Health and Environment suspended their license to operate and escorted willing residents to new assisted living homes.

Through a CORA request KRDO obtained a Summary of Suspension, outlining why state officials elected to suspend their license.

According to the state's findings, residents living with mental health issues consistently were without their medications. Residents who refused to take their medications for months demonstrated violent behaviors without penalty.

One resident threatened a neighbor with a knife. Another resident set several objects on fire on multiple occasions. A third resident would smoke cigarettes inside her apartment while using an oxygen tank. Homeless were allowed to sleep in the apartment of one of the residents.

A judge will ultimately decide if the facility's temporary license suspension will become permanent.

KRDO reached out to the owners of the facility, Paul and Alan Spicola, but they couldn't be reached for comment.

Several residents were not willing to leave the apartments, and still live in their homes. It is unclear who is looking after those residents.

Pueblo County Adult Protective Services did not respond to requests for comment.


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Pueblo assisted living home put residents in danger, loses license after state investigation

'She was my best friend:' Daughter's claims after mother's death prompts state investigation

FAYETTEVILLE, N.C. (WTVD) -- A Cumberland County woman is in search of answers after she said her mother's death at a rehabilitation center could have been prevented.

In early January, Susan Bullock's 70-year-old mother, Elizabeth Cook, was admitted to Carolina Rehab Center of Cumberland in Fayetteville to "get her health back up."

Bullock, however, had no idea just nine days later her mother would be dead.

According to Bullock, the facility waited too long to notify her that her mother fell out of the bed.

"She would still be here today had they contacted us," Bullock said. "I just don't understand how somebody makes a fall out of the bed ... and ends up like that."

Bullock's claims led to an investigation by the North Carolina Department of Health & Human Services. The agency's findings show Carolina Rehab failed to notify Bullock or other family members of Cook's fall in a timely manner.

It took staffers more than two hours to contact Bullock.

"They did not treat her," Bullock said. "I asked for all kinds of tests."

Bullock alleged that the center failed to provide adequate care by way of neglect and abuse. The state investigation determined those claims were unfounded.

"I asked (the facility) is this how you guys treat every elderly person in here," Bullock told ABC11. "Their excuse was that they've had several people quit."

The investigation also detailed that the center addressed or planned to address inadequacies brought forth by the state.

"She was my best friend," Bullock said of her mother.

The official cause of death as listed on Cook's death certificate lists "healthcare-associated pneumonia" and "COPD." Bullock said before her mother's admittance into the facility, doctors gave Cook a "clean bill of health."

In a statement to ABC11, Carolina Rehab Center of Cumberland wrote, "Privacy laws prohibit us from addressing the specific allegations. We do think it is important to separate opinions from facts. We fully investigate concerns when they are brought to our attention. We stand by our commitment to our patients and take great pride in the care we provide."

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'She was my best friend:' Daughter's claims after mother's death prompts state investigation

Troubled Pensacola assisted care facility forced to close

A Pensacola assisted living facility's license will be revoked after a state investigation found one negligent death, untrained staff and poor practices allegedly took place at the center.

Little Friends Learning Center, which conducts business as Alpine Adult Care Center, will be out of operation by the end of the month following a settlement agreement between the company and the Florida Agency for Health Care Administration.

On March 9, the AHCA issued an emergency moratorium on admissions to the center after a weeklong investigation into the 14-bed facility on Louisiana Drive. The case concluded May 8 when the AHCA issued a final order to revoke the center's assisted care license.

The facility was fined $50,000, though $47,000 of that will be stayed as long as the facility doesn't again operate under an assisted care license.

The order states the center can operate through May 31, but only to collect and distribute patient records and safely remove existing patients from the facility.

The settlement agreement states the facility and its director, Sue Ann Thompson, cannot apply for an assisted care license in the future. It also states that by May 31, both must surrender their licenses and show documentation that each of Alpine's patients has been relocated to another licensed facility.

Thompson and her attorney could not be reached for comment Tuesday.

The AHCA's original investigation unearthed the use of expired or improper medications, inadequate record-keeping that resulted in staff not knowing patients' end-of-life wishes and staff who had not been properly trained, according to the moratorium documents.

One patient whose case was highlighted in the documents died last year after what the AHCA suggested was negligence. The patient was in hospice-level care and was under a doctor's orders to take breathing medication four times a day, as well as an inhaler daily to help with symptoms.

The AHCA report suggests Alpine Adult Care Center staff were habitually lax with those medication requirements, and six hours before the patient's death, staff didn't administer the scheduled early-morning dosage. The patient was found unresponsive on the bathroom floor on Nov. 14, but wasn't resuscitated. Emergency responders pronounced the patient dead soon after. Three of the four Alpine staff members who responded to that patient weren't trained in resuscitation, the documents state.

The AHCA's complaint against Alpine, included with the final order, states six patients' cases were reviewed, and each one received inadequate care, largely surrounding issues of improper medication dosages or administering.

In some cases, the staff interviewed by the AHCA said they administered dosages of some medications, but didn't keep records.

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Troubled Pensacola assisted care facility forced to close

State investigates Modesto nursing center over patient transfers

By Deborah Schoch and Ron Campbell
CHCF Center for Health Reporting

Jill Hernandez knew something was wrong as soon as she got the request from a Lodi nursing home.

A new resident had just arrived from Vintage Faire Nursing and Rehabilitation Center in Modesto – a woman with no family and with severely impaired mental skills. The Lodi home asked Hernandez to represent her in making decisions about her care.

“How did she get there? Who signed her out?” asked Hernandez, the long-term care ombudsman program director for San Joaquin County, where Lodi is located.

Hernandez met with the woman. Then she complained to the California Department of Public Health, prompting an investigation of Vintage Faire.

The story widened. The Modesto home had shipped a total of seven long-term residents in March to two sister nursing homes in San Joaquin County, according to state records. One resident said she had only 15 minutes to decide whether to go.

Vintage Faire failed to notify most families and friends of the transfers. At least four of the residents, all women, were diagnosed as severely mentally impaired.

One mentally challenged woman later told a state investigator that she walked the 38 miles from Modesto to Lodi, demonstrating by moving her legs back and forth, records say. Another woman said that “she did not know why she was there, how she got there or where she was.”

“It was shocking to me that someone would do that, that a facility would just send them out like that,” Hernandez said in an interview.

Her complaint led to a state finding that Vintage Faire had transferred the residents “without medical justification as necessary for resident welfare, needs or safety,” a violation of federal regulations. The fine: $2,000.

A key question remains unanswered: Why did Vintage Faire want to transfer those patients?

The facility won’t comment, citing the fact that it has appealed the citation.

But according to hundreds of records obtained by The Bee under the state Public Records Act, the home’s staff told some residents and families that it was removing long-term residents to make room for more short-term patients.

“It says that right in the citation. It’s pretty darned explicit,” said Tony Chicotel, staff attorney with California Advocates for Nursing Home Reform, or CANHR, a San Francisco-based nonprofit. He said he has seen similar cases at other homes.

Chicotel said “short term” is code for higher-paying Medicare patients and that long-term refers to residents on low-paying Medi-Cal insurance for the poor.

Andrew F. Torok, general counsel for Covenant Care, which owns Vintage Faire and more than 50 other facilities, would not comment on the transfers by Vintage Faire. But he said his company doesn’t engage in transferring long-term residents for monetary gain.

“That’s not how we operate,” Torok said. “Our culture is one of doing the right thing, for the right reason. It would be absolutely unthinkable that we would do something like this.”

In a corrective plan sent to the state, the facility said it would assure “safe and proper discharges in accordance with federal requirements.” It promised to audit long-term care discharges for three months and review patterns of noncompliance.

On average in California, Medicare pays nursing homes roughly three times the daily rate that Medicaid pays. That’s because Medicare pays for short-term, intensive rehabilitation after a hospital stay while Medicaid – known as Medi-Cal in California – pays for long-term care.

Last year, a typical Medicare stay in a nursing home lasted 51 days, according to Medicare data. A Medicaid stay could last several years, often until a resident’s death.

State records do not show if the seven residents were on Medi-Cal.

Deborah Pacyna, a spokeswoman for the California Association of Health Facilities, said she is not familiar with the Vintage Faire case and could not comment. She cautioned, however, against assuming a single example could signal an underlying trend.

“We reject any allegations that patient admissions or discharges are tied to payment sources,” Pacyna wrote in an email.

Patients later evaluated

The woman known as Resident 1 had lived at Vintage Faire for nearly 15 years when the home approached her.

An aide told state investigators that the woman was asked if “it was OK to transfer her, and she said it was.”

So Resident 1 was placed in a van on March 27, bound for the Arbor nursing home 38 miles away in Lodi.

Her story, and that of the six other transferred residents, is described in the July 6, 2015, citation that the state issued to Vintage Faire. The citation refers to them as Residents 1 through 7 to protect their privacy.

The day after Resident 1’s transfer, a state evaluator visited Arbor and talked with the woman in her new room, filled with Barbie dolls, toy firetrucks and a dollhouse-sized firehouse. The woman stated “fireman” and pointed at the firehouse.

“Resident 1 nodded her head or said ‘yes’ to questions but was unable to respond in complete sentences,” according to state records. She was interviewed to assess her cognitive ability, scoring 0 on a scale of 0 to 15. Any score of less than 7 is considered “severe cognitive impairment,” the records state.

Two other transferred residents scored 5 and 3 on the same scale.

Another woman, Resident 4, a Cantonese speaker and a resident since 2007, is described in records as “severely impaired – never/rarely makes decisions.”

A man described in the state records as her “responsible party” said Vintage Faire contacted him the day she left, to say she was being transferred and that the home was “getting rid” of long-term residents. He said her relatives could not easily visit her in Lodi because of transportation problems.

Her family had visited her frequently in Modesto, speaking in Cantonese and bringing home-cooked food that she ate with them in the dining room, where she always ate, records say. In Lodi, she ate most meals in her room.

Resident 7’s friend found her missing just two days after bringing her fresh laundry. Vintage Faire had moved her to Arbor without notifying the friend, who held power of attorney for her health care needs. The facility’s staff said they could not locate the paperwork.

“They just sent her. She was not prepared,” the friend said.

Arbor’s staff wrote in her clinical record that she described herself as depressed and frustrated, saying, “Things just aren’t going well for me.”

Vintage Faire’s director, who is not named in state records, told investigators that she received a call in March from the company’s regional director of operations, telling her that another facility had some open long-term beds and that any resident who wanted could transfer there.

The home’s director said she told two social services aides to make the offer to alert, oriented residents. The aides were not adequately trained, she added, and she should have supervised them. (Continue Reading)

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State investigates Modesto nursing center over patient transfers