According to the Kaiser Family Foundation, North Carolina spent close to $1.2 billion on nursing homes for elderly Medicaid recipients in 2013.
According to the Kaiser Family Foundation, North Carolina spent close to $1.2 billion on nursing homes for elderly Medicaid recipients in 2013. Image courtesy Derrick Tyson, flickr creative commons

By Thomas Goldsmith and Rose Hoban

Pointed questions arose about drastically low staffing and apparent failure to plan by Kinston-based Principle Long Term Care after its facility Pine Ridge Health and Rehabilitation faced a crisis on the icy night of Jan. 16.

By the time local EMS and government officials showed up, two residents had died at the Thomasville home and nearly a hundred were left in the care of one nurse and two assistants instead of the 13 to 15 who should have been providing care.

In response, legislators called a state NC Department of Health and Human Services manager to testify before a March 15 meeting of the Joint Legislative Oversight Committee on Health and Human Services. Emery Milliken, deputy director of the Division of Health Service Regulation, the DHHS division that oversees licensing and regulating nursing homes in the state, laid out the scenario that led to multiple high-level penalties against Pine Ridge. 

The citations included 13 areas of deficient practice that investigators discovered, including eight so serious as to put residents’ lives and safety in immediate jeopardy. 

Throughout her time at the General Assembly’s Joint Legislative Oversight Committee on Health and Human Services, neither Milliken nor any legislator mentioned the name of facility owners Principle Long Term Care. The company is listed in federal records as owners of 38 North Carolina nursing homes. According to a 2021 contract bid to the state Department of Administration, Principle has been in operation since 1980. 

DHHS information officers pointed out Tuesday that Principle is mentioned in DHSR’s comprehensive report. In fact, it is mentioned twice, on pages 150 and 155 of a 159-page report, although there are more than 100 references to “corporate” executives and staff.

“No legislator asked about the corporate ownership during the question and answer session,” Catie Armstrong, DHHS press assistant, wrote in an email. “The focus of the presentation, as requested by the legislature, was about the investigative findings of the incident.”

In addition, Principle did not figure in most news accounts of the Pine Ridge problems. An Associated Press item reflected a complaint from Principle that the Pine Ridge deaths had been wrongly portrayed as linked to staffing shortages. The deaths had not been medically related to low staffing, a Principle official told the AP. Calls by NC Health News to Principle’s headquarters were not returned Monday and Tuesday.

‘Back out of the way’

At the legislative hearing, state Rep. Larry Potts (R-Lexington) said he had learned that icy weather prevented the transportation of bodies of two residents who had died earlier in the day.

“So they were just pushed back out of the way,” Potts said after the meeting. “I was more concerned about the living who had to call 911. I talked with the first officer on the scene and the district attorney about the conditions there.”

Although Pine Ridge is not located in Potts’ district, he said that local officials frequently call him when issues in the community arise as he was a county commissioner for several decades before going to the state legislature. 

Testimony before the committee showed that a disaster plan prepared and submitted to state regulators under a previous Principle administrator was ignored under a replacement who took over the job three months after state regulators had reviewed the plan. 

Nine days before the Pine Ridge incident, a report from the Centers for Medicare and Medicaid Services indicated that nursing homes with higher levels of turnover garnered lower overall ratings. The staffing shortage took place on a Sunday, during a weekend period identified by federal officials as critical for nursing home quality.

“This incident happened January the 16th through the 17th and it began to unfold at Pine Ridge as the snowstorm began to hit on the morning of the 16th,” Milliken told the committee. “The Health Services Regulation investigation found that as weather conditions worsened, many staff who were scheduled to come to work that day at Pine Ridge, either didn’t show or they left early because of the road conditions.”

On the federal Medicare.gov nursing home ratings website, Pine Ridge garners only a one-star rating out of a possible five stars, something listed as “much below average.” For the staffing metric, Pine Ridge’s rating is a scant two stars out of a possible five. 

The January incident resulted in Pine Ridge receiving a federal designation of immediate jeopardy, denoting a situation in which a facility has put the safety and health of residents, “at risk for serious injury, serious harm, serious impairment or death,” according to the CMS compliance manual. It’s the most serious sanction a nursing home can face and can result in immediate closure of a facility or loss of the ability to bill federal payers for reimbursement. 

Residents unfed and ungroomed

That meant that so few Pine Ridge staff were on hand that residents were reduced to calling public emergency services. 

“These 911 calls reported the caller needed help, that she hadn’t seen staff for hours, couldn’t reach staff, that she was wet,” Milliken said.  “She was hungry and had not had supper.”

According to Milliken’s presentation, 98 residents had one licensed practical nurse and two nursing assistants to look after them from 2 p.m. Sunday, January 16 until emergency responders arrived to help that night. The typical staffing would involve 13 to 15 people, she said.

Neither the administrator at the time nor the director of nursing was there to help residents, according to a 159-page Division of Health Service Regulation investigative report that included an interview with the unnamed administrator. 

“She said she and the Director of Nursing had tried to come into the building, but they were unable to because of the poor road conditions from the inclement weather,” investigators wrote. 

Principle’s failed bid

This wasn’t the first time Principle had come under the state’s scrutiny. During the 2021 process to select a management company for the state’s veterans nursing homes. Principle was ruled out by an evaluation team from the NC Department of Military and Veterans Affairs, even though it offered to run the homes for the lowest percentage of revenue among three applicants. 

The team said it found Principle lacking in part because it relied only on information only from the previous three and a half years of operation and in part because of its use of an “extensive list” of contractors to operate its facilities. In looking into a reason for a 2017 corporate reorganization, the evaluation team cited a case in which employee Douglas S. Little was convicted in Union County of second-degree forcible sex offense against a resident of Lake Park Nursing Home in Indian Trail.

Another immediate jeopardy

Principle also came under state sanctions in 2020 when investigators documented a threat of immediate jeopardy to a Pine Ridge resident. According to the DHHS-generated report, Pine Ridge staff failed to “document, report, assess and seek medical treatment for” a resident with severe cognitive problems who was a fall risk but was walking by herself when she fractured her forearm, wrist and the socket of her hip joint.

A technician saw the fall and pointed it out to other staff, according to the report, which also noted that the resident “cried that she was in pain and when the nurse came into the room he told us it was our fault that she fell because we did not monitor her close enough. The nurse instructed the NAs to put her in her wheelchair and take her to her room and put her to bed.” 

The resident, who fell at about 8:30 p.m. on Oct. 6, 2020, did not receive an assessment, treatment or pain medication until after 11 a.m. the next day, investigators found, despite the resident’s tears and complaints of pain.

State Rep. Donna White (R-Clayton) said after the meeting that the problems of low staffing and poor planning are not unique to Pine Ridge and its horrific snow day. 

“I can tell you that’s not the only facility in North Carolina that has those issues,” White said.

“It could be a fire, it could be anything else, it could be a hurricane, it could be a tornado. It could be another pandemic. 

“I understand that all these things have been spotlighted more because of the pandemic. But the underlying issues were already there.”

Correction: This story originally stated that Rep. Donna White was a Democrat.

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Thomas Goldsmith

Thomas Goldsmith worked in daily newspapers for 33 years before joining North Carolina Health News. Goldsmith is a native Tar Heel who attended the UNC-Chapel Hill, and worked at newspapers in Tennessee...

Rose Hoban

Rose Hoban is the founder and editor of NC Health News, as well as being the state government reporter. Hoban has been a registered nurse since 1992, but transitioned to journalism after earning degrees...