The man, known in federal documents as Resident No. 1, was wearing his hospital gown, underwear and socks, lying on top of some rocks in a drainage ditch. The ditch had a small amount of water in it, and part of his gown was wet. About three feet away sat his shoes.
On a March morning a year ago, the sun was just coming up, and the man, with his arms folded across his chest, was looking up at the sky.
The cars in the parking lot had frost on their windshields.
The man heard Nurse No. 1 call his name.
“Yeah,” he answered.
The man was cold, so very cold.
Nurse No. 1 helped transport the man the 178 feet to his room at the Carolina Point nursing home. Two hours earlier, the man, who was having a restless night, had escaped through an emergency door in Hallway 300. Once back in his room, medical staff took his temperature: 90.7 degrees, Stage 1 of hypothermia.
Carolina Point, a for-profit nursing home  at 5935 Mt. Sinai Road in Orange County, has a lengthy history of health and safety violations and fines, federal records show. Residents have repeatedly complained about the quality of the care, according to county documents, including indifferent or abusive staff.
Now Carolina Point and its residents face a life-threatening crisis. A coronavirus outbreak there has infected 60 people, hospitalized seven with COVID-19 and resulted in two deaths.
“These are shockingly large numbers,” Gov. Roy Cooper said at a press conference Wednesday afternoon.
Alongside Cooper, Secretary of Health and Human Services Mandy Cohen discussed the outbreak but declined to name the facility, citing patient privacy issues. However, PruittHealth’s main website designated its Carolina Point facility as a “code red” because of coronavirus infections. The name of the facility was later confirmed by the Orange County legislative delegation: Reps. Graig Meyer and Verla Insko, and Sen. Valerie Foushee.
The PruittHealth communications department issued a statement: “Carolina Point began operating at Code Red status as soon as we received notice of the first presumptive positive COVID-19 patient. Under the guidance of public health officials, enhanced infection prevention protocol was implemented. We are actively monitoring staffing levels, appropriate supplies of personal protective equipment (and have installed an air scrubber system. We also have built isolation units to work to contain the virus.”
All of the residents have been tested, according to the communications department, and the facility is “actively communicating with these residents’ families.”
PruittHealth operates nursing facilities in Georgia, South Carolina, North Carolina and Florida.
Secretary Cohen said new protocols are now in place to prevent additional outbreaks at nursing homes. Residents who test positive but aren’t hospitalized must be separated into their own area of the facility and tended to by staff assigned only to that unit. Visitors are already prohibited from entering, but now all staff must wear masks and close communal areas, such as dining areas. Staff must be screened for illness each day.
“If an outbreak happens, quick action must happen,” Cohen said.
Before PruittHealth opened Carolina Point, the facility was known as the Forest View Rehabilitation Center, run by another for-profit company, the Epic Group. In the early 2000’s, federal and state investigators found critical, even life-threatening health and safety violations there : Some residents had deep, penetrating bed sores. Other residents had sexually assaulted by fellow patients. One man, who could not speak, was swarmed by 150 fire ants and had developed large welts from being bitten.
Forest View closed in 2008 after the Centers for Medicare & Medicaid Services in Atlanta stripped the facility of its certification to receive Medicare and Medicaid reimbursements.
Since PruittHealth has taken over, the care has been a step up from fire ants, documents show, but its care still is suboptimal. Carolina Point is licensed is for 138 beds, according to federal records. The facility’s website claims it has received a four-star rating from the federal website Medicare.gov. That’s not true. The Centers for Medicare and Medicaid Services has rated Carolina Point as a one-star facility out of a possible five. According to the Nursing Home Compare profile on medicare.gov, the facility has been cited for abuse.
Last year, Carolina Point was fined nearly $15,000 for violations.
Staffing levels are well below average, according to federal documents, with each resident receiving just 20 minutes of care each day from a registered nurse, about half the amount of time at other nursing homes in North Carolina and the nation, which devote roughly 40 minutes per day.
Carolina Point ranks below the national and state average on several key benchmarks, according to the Centers for Medicare and Medicaid Services. The average person count is 132, compared to 85 statewide. Nearly 43% of long-term residents are less able to independently move during their stay; in North Carolina, the average is 23% and nationally it’s 17.5%
The lack of staffing and its inattentiveness allowed Resident No. 1, the man with dementia, to leave his room in the middle of the night and go missing for nearly two hours.
And staffing isn’t the only problem. According to site visit summaries  filed by the Orange County Nursing Home Advisory Committee and federal documents, Carolina Point has racked up citations and violations for myriad issues, ranging from a filthy kitchen to expired medications to a failure to administer critical medicines to a resident on time.
In 2019, a staff member broke a resident’s finger while trying to dress her, documents show.  That staff member was later suspended. Residents have reported waiting hours for staff to respond to a call bell. One resident complained “of being wet for several hours before anyone assisted him,” county documents say.
In August, one resident “was observed drinking liquid hand sanitizer.”
A new director of nursing was hired in mid-2019 to help upgrade services at the facility. But during the most recent site visit on Jan. 7, 2020 , Orange County Nursing Home Committee members who visited Carolina Point noted that it needed to “improve staff courtesy, food choices, nail care and opportunity for activities.”
The following entry is from the site notes on the Jan. 7 visit:
“One family member sought out committee members; very distressed about trying to help spouse late at night via telephone call to staff. Spouse asking to use urinal; staff response heard by wife was ‘we’re going to put you in a diaper’ when resident asked for assistance with urinal.”
The spouse then called back, the site notes read, when she asked to whom she was speaking, a staff member allegedly responded “you don’t need to know.“ The nursing supervisor said she would immediately address the situation, according to the notes.
In 2018, documents show  residents complained about the lack of adequate staffing, and workers who were clearly exhausted:
It was pointed out that many night shift staff are working two jobs and had been observed sleeping in the break room during shifts. One resident noted that call bells go off throughout the night unanswered and that sometimes one staff member covers two floors. … It was felt that call bells or cries for help were ignored. The person who said she had waited 40 minutes for pain medication said she did not push the call button again as the person responding would become upset with her.”
In 2017, there was an outbreak of a different, unnamed disease — it’s not unusual for nursing homes — and a county report stated “[there was a] written notice of a communicable disease. We were also cautioned by the Nursing Director, when we arrived, to not touch any residents on certain halls.”
Resident No. 1, the man  who had escaped from Carolina Point one spring morning in 2019, was taken by ambulance to the hospital. There, his body temperature gradually rose to within normal range and he returned to Carolina Point the same day. No one on the nursing staff at Carolina Point knew how Resident No. 1 had opened the emergency door to the 300 Hallway.Someone would have had to have disengaged an emergency switch to open it. Or perhaps someone propped open the door.
Investigators concluded they were unable to determine who or why the 300 hallway exit door was disengaged.