Roanoke nursing home being investigated for possible neglect after two police reports were filed, resident had two toes amputated

Some may find details within this story graphic and disturbing

ROANOKE, Va. – Allegations of neglect have arisen within a Roanoke nursing home after families have been unable to see their loved ones in person for months during the coronavirus pandemic.

Two cases are now part of an ongoing police investigation, one of which led to a complaint filed with a state agency.

Julie Parsons spent her last day with her 96-year-old grandmother back in November.

“I was always there with my Nannie. I was her biggest advocate. We were together all the time,” said Parsons.

She said Helen Norfleet, who suffered from multiple ailments, moved into Raleigh Court Health and Rehab Center in 2018.

[‘She was in deplorable condition’: Allegations of neglect in a Roanoke nursing home]

While her grandmother was there, she would visit her multiple times a week; however, that all changed when the coronavirus pandemic hit.

“March 13th was the last day I was there in the facility,” said Parsons.

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While no in-person visitors were allowed, Parsons stayed in touch with video calls and said that everything was fine for a while.

“But then we started noticing a decline. I noticed her hygiene was not well. Her hair would just be so greasy it would look wet,” said Parsons.

Parsons says her grandmother had hair that was so greasy it looked wet. (Courtesy: Julie Parsons)

In September, Parsons said she got a call that her grandmother tested positive for COVID-19 and the next day she was told she had fallen out of bed.

“I asked, ‘how did that happen?’ She has bumper pads on her bed I was informed that the bumper pads were not on her bed that morning and she fell out of the bed and busted her face, and it broke her glasses,” said Parsons.

Then came October.

“I was notified that Nannie had two wounds on her toes on her left foot and they were going to be watching those and taking care of those,” said Parsons.

Parsons and Norfleet celebrate in October (Courtesy: Julie Parsons)

Parsons said when they celebrated her grandmother’s birthday at a window visit, her face was still bruised from the fall in September and her foot was wrapped.

Weeks later, Parsons said she received another call.

Parsons says her grandmother's hair was put up with scotch tape. (Courtesy: Julie Parsons)

Her grandmother’s foot was getting worse and Parsons decided she wanted her taken to the hospital, where she eventually needed two toes amputated. She met her grandmother there, where she took a picture showing Norfleet’s hair put up with scotch tape; however, that wasn’t the worst of it.

“She was bruised all across her chest. She was bruised on her shoulder. She was bruised on her legs. She had a bed sore on her bottom,” said Parsons. “When they took the bandage off, the bone was exposed on her second toe, you could see the bone sticking out.” Parsons said that after the amputations, the family made the decision to move her to another facility.

Parsons took these pictures at the hospital (Courtesy: Julie Parsons)

But in November, her Nannie went back to the hospital, was put on hospice and died one day later on Nov. 20, 2020.

10 News pulled search warrants and found two cases being investigated for two different women who have lived at Raleigh Court Health and Rehab Center.

The first search warrant showed investigators wanting Norfleet’s medical records for the time she was at Raleigh Court as they looked into possible neglect against the 96-year-old.

According to the warrant, in October, a report was filed with adult protective services and Roanoke Police stating, “the level of care decreased dramatically once the facility stopped allowing visitors… it was determined that Norfleet had an infection on her toes that required amputation”.

[See the entire Roanoke City Police search warrant here.]

Our investigation also found a December report from the Virginia Department of Health’s Office of Licensure and Certification, that detailed the following:

  • The quality of care requirement was not met by Raleigh Court Health and Rehab Center
  • “Facility staff failed to provide assessment and treatment” of a wound “as evidenced by failure to treat and assess a non-pressure skin wound as it progressed to a full thickness wound for 1 of 3 residents in the survey sample (Resident #1).”
  • Concern that her foot was not assessed by a physician for more than two months and that “the time gap between the first physician assessment documenting the foot wounds on 8/11/20 and the next physician assessment on 10/21/20 (exacerbated by the failure of the physician to assess wounds on 10/7/20) contributed to the resident being transferred to a higher level of care and a delay in treatment.”
  • The “failure to regularly document” the condition of the wounds “made it impossible to determine when the wounds formed and the resident’s condition deteriorated”.
  • The state surveyor was “unable to determine who ordered the wound physician consultation, when it was ordered, or what the resident’s condition was at the time.”
  • The state surveyor concluded that these “failures constituted neglect of the resident that resulted in harm to the resident”.

Raleigh Court stated in part in its Plan of Correction, filed last month, that its plan is “not an admission to and do not constitute an agreement with the alleged deficiencies nor the reported conversations and other information cited in support of the alleged deficiencies.”

Furthermore, Raleigh Court stated in its plan that current residents were reviewed for “skin impairments and to ensure assessment and treatment is accurate”.

The plan also states that nurses were educated and “nursing leadership will review current residents with skin impairments weekly for eight weeks”.

[See the entire Statement of Deficiencies and Corrective Action Plan here.]

VDH said that the citation will require an unannounced re-visit.

“My Nannie went peacefully but I think about the absolute neglect and the horror that my Nannie must have went through. My Nannie went from ‘When are you coming over here?’ to ‘I need you to come over here’.”

Our investigation found four other reports for Raleigh Court listed on the VDH website going back to 2016 that have been investigated and the facility had to provide a plan of correction.

This 10 News investigation also found another search warrant asking for medical records of another woman in her 90s who lived at the facility.

[Vital information missing on government websites to research nursing homes]

It says that on Nov. 29, 2020, a month after Norfleet’s condition was reported to Roanoke City Police and Adult Protective Services, a case involving another individual was reported.

The search warrant says “staff obtained an Emergency Custody Order. Staff advised she may have a UTI and that was most likely the cause of her problems. Staff then contradicted themselves to Officers and stated (resident’s name) was not suicidal or homicidal.”

The search warrant goes on to say when she was brought to the hospital “she had a large amount of dried fecal matter in her diaper”… and on her body but “had on a clean diaper”. The warrant says she was “raw and red”… “due to the large amount of fecal matter.”

10 News contacted the Commonwealth’s Attorney about both cases to see if charges have been filed. We’re told both cases are being reviewed and more people need to be interviewed.

We asked for an interview with Raleigh Court, but they declined and sent us these statements from Administrator Chance Craft:

“As a leading provider of skilled nursing and rehabilitation services, we are held to strict standards and we take our role as healthcare provider very seriously. While a family member and a clinician’s perspective will often vary in regards to a loved one’s health condition, we are unfortunately precluded from commenting due to privacy laws. We remain committed to our patients and take great pride to serve as a trusted caregiver.

We are fully staffed with all levels of clinicians in the center and continue to have outstanding relationships with our attending and consulting physicians. We believe it is important to thank, and support, those who step up day-after-day to provide skilled assistance to patients that need it - often as they navigate extremely complex healthcare situations.

Last year Raleigh Court participated in six regulatory surveys. As a result, we are very proud to have earned the coveted CMS five-star rating which recognizes us as one of the best skilled nursing facilities in the nation. This recognition celebrates the highest levels of care delivery in our industry and is a testament to the passionate and high-quality clinicians we have serving our patients every day. Through this pandemic and beyond, we are incredibly thankful for their contributions.”

“In addition to our previous statement, while state and federal laws do not allow us to comment on the care or circumstances surrounding any individual patient, we can confirm that we operate in a heavily regulated industry that has mandatory reporting requirements and other intentional measures to ensure that vulnerable patients are thoroughly protected. We strongly believe in the value of these processes and procedures and stand proudly on our long track record of providing excellent care.”

But Parsons said she’s not done fighting.

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“I really believe that if families were allowed to still go into facilities and visit their loved ones and kind of be that checks and balances none of this would have happened. I really honestly believe that,” said Parsons. “My prayer is that not one more person endures what my nannie endured.”

The Roanoke City Commonwealth’s Attorney, Don Caldwell, told 10 News it can take up to 90 days to complete the investigation and he expects it will take at least another month.

10 News will continue to follow this closely.

If you want to take a look at reports concerning this facility or any other you can look up reports on the VDH website here.

This is part of an in-depth 10 News investigation. Jenna Zibton is working for you, investigating different angles of what COVID-19 means for families with loved ones in nursing homes. Contact Jenna if you have questions at or on Facebook.

About the Author

You can see Jenna weekday mornings at the anchor desk on WSLS 10 Today from 5-7 a.m. She also leads our monthly Solutionaries Series, where we highlight the creative thinkers and doers working to make the world a better place.

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