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

A warning, some may find the details within this story disturbing

A warning, some may find the details within this story disturbing

ROANOKE, Va. – A 10 News investigation has found another case of possible neglect after our first story in March.

Thousands of cases are opened every year in Virginia and about half are confirmed. The number of elderly people becoming victims continues to rise across the Commonwealth.

10 News is working to uncover new details about elder care during the pandemic and why efforts to protect our elderly, may have done the opposite.

[What you can do to protect your loved ones living in nursing homes]

“We brought her here to hospice and she went about four days and it was the toughest thing I’ve ever done in my life,” said Jim Gregory, through tears as he talked about the last days his mother was alive.

He wishes he could call his mom, “She would normally answer the phone, ‘Hey sweetie, how you doing?’”

Lillian Gregory fell at home in October 2020, broke her femur and never recovered.

“I miss calling her every morning. It hurts,” said Gregory.

She went to the hospital, then spent a couple of weeks at a nursing facility before being transferred to Raleigh Court Health and Rehab.

Gregory said that after weeks there, she wasn’t herself, “We were really, seriously concerned now. The calls, she was very weak. It was like not Mom.”

Gregory went there and after a rapid COVID test, was allowed inside the facility.

“She was on death’s doorstep. It’s probably why they let me in, and I was able to hold her hand,” recalled Gregory, who took pictures of his mom at Raleigh Court before she was taken to the hospital. “She was in deplorable condition.”

Photos Jim Gregory took of his mother. (Jim Gregory)

Our 10 News investigation found a police search warrant, asking for medical records for the 86-year-old from November through January 2021.

Click here to read the search warrant

We’re told this is still an active police investigation, one of three at Raleigh Court.

There are three active police investigations going on into possible neglect at Raleigh Court Health and Rehab Center.

The document said a report was filed with police alleging that Lillian Gregory was neglected.

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

The allegations in the search warrant include that “…in the two months she was at Raleigh Court Gregory was abused, lost weight, developed several health problems…”

“Her tongue was black. Her teeth were missing. The teeth that were there were black. Her toes were orange. The bedding was soiled still, wet,” remembered Gregory, about when he saw his mother inside Raleigh Court.

We discovered four referrals filed with Roanoke City Adult Protective Services who investigated and sent this letter saying “…there is a preponderance of evidence that Lillian Gregory was a victim of abuse, neglect or exploitation…”

Click here to read a letter sent from Roanoke City Adult Protective Services to Raleigh Court Health and Rehab

One APS referral said when she was seen in the ER, there was a “...rectangular bruise that covers 3/4 of her abdomen. The bruise appears to be patterned and looks as though it may have come from a strap being used to keep Lillian upright in a chair.” There were “pressure ulcers on her butt and on her heels, and her heels had deep tissue injury.” The ulcer on her “sacrum was unstageable because the bottom of the wound could not be seen due to so much dead tissue.”

“It was one of those things that you feel responsible for because I should have yanked her out of there a long time ago, but I didn’t and I’ll live with that the rest of my life,” said Gregory.

Lillian Gregory died on January 21, two months after she was first admitted to Raleigh Court.

“We are seeing some alarming situations,” said Joani Latimer, Virginia’s long-term care ombudsman, who works for the Virginia Department for Aging and Rehabilitative Services.

[How Virginia lawmakers are pushing for changes to the state’s nursing home system]

Local ombudsmen serve as advocates for those living in places like nursing homes.

Our investigation found that 12,002 Adult Protective Services cases were substantiated from March 1, 2020, through February 2021 across Virginia.

The Virginia Department of Social Services divides the state into five regions and the one that contains Roanoke, Lynchburg and Danville, the Piedmont region, had the most cases with 3,498.

More than just those three cities, the Piedmont region covers from Highland County down to the North Carolina border and from Roanoke County as a western border to Charlottesville as an eastern border. The area highlighted in yellow below shows all 32 counties and cities that comprise the region.

VDSS Regional boundaries (VDSS)

Across Virginia, the data shows more than 4,500 instances of neglect, physical, mental, or sexual abuse.

“This has been a perfect storm in a terrible sort of way,” said Latimer, who added that amidst the COVID-19 pandemic, nursing homes essentially had no oversight. “To a large extent we don’t totally have that picture. I think it’s just now unfolding as programs like ours, as regulatory agencies are back in long-term care settings because there has just been no way to see exactly what’s been going on.”

Latimer said once ombudsmen weren’t allowed in because of COVID restrictions, complaints dropped about 35% and now the complaints are picking back up.

“The problems, the concerns, the care pitfalls are greater. There are things like day-to-day care, personal hygiene which sounds like not such a big deal maybe; however, we all know there is a cascading connection between that and development of bed sores, so people aren’t taken to the toilet in a timely manner, are sitting in waste, etc., are not turned properly if there are not enough staff to do that in a facility,” said Latimer. “Those are the sorts of things that become particularly glaring, glaring concerns.”

We asked Latimer, “Do you think had ombudsman been allowed in these nursing facilities that they would have been able to catch some of these things before they got as exacerbated as they are now?”

“Intuitively I would say, there would have been things that we would have become aware of and helped to address but we weren’t there to see,” said Latimer.

Gregory wants other families to pay more attention saying, “They need to be looked in on and monitored especially right now. They need to have people looking into what’s going on in there whether there’s COVID or not.”

Raleigh Court’s Administrator Chance Craft said they can’t comment on patients, but he sent 10 News this statement:

“While privacy laws at both the state and federal level prohibit us from commenting on the specifics of any individual patient’s circumstance, we stand by the quality of care that we have always delivered. Raleigh Court is a five-star facility that has earned and maintained this exceptionally high industry ranking through continuous third-party audits and evaluations. We understand that the death and dying process can be very difficult for patients and families and, even medical professionals can differ in their opinions. Still, our skilled staff show up every day to care for those who need support - even in the most challenging of circumstances. We are incredibly thankful for their service, as are the hundreds of families we have partnered with over the years to navigate challenging illnesses, rehabilitation, and, at times, even highly emotional end-of-life care.”

10 News will continue to follow this closely.

To see the steps you can take if you have concerns about a loved one, including how to find your local ombudsman’s office click here.

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 jzibton@wsls.com 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.