THOMASVILLE, N.C. (WGHP) — The final report was released Monday after the Division of Health Service Regulation’s nearly two-month investigation into two deaths at the Pine Ridge Health and Rehabilitation Center.

One licensed practical nurse and two nursing assistants were on-site to care for 98 patients. Two patients were found dead by authorities, and two other patients were found in critical condition.

The final report says the facility had an emergency preparedness plan, but it never got communicated to the employees despite the fact Governor Roy Cooper announced a state of emergency on Jan. 13.

The day shift staff did not show up on Jan.16, and people working the night before stayed to cover but got to their tipping point.

The 159-page document details the timeline of the night of the snowstorm.

Interviews reveal at about 4:30 p.m., one nursing assistant was “crying asking if anyone else was going to come to help and had a panic attack to the point where she felt she may have to call 911.”

Patients inside the facility started calling 911 after having trouble locating staff.

One woman first called at 5:19 p.m. on Jan. 16 saying she had not seen staff, they had no dinner and she was wet in her bed.

She called again at 8 p.m. and said she still had not seen anyone and needed help.

At 8:09 p.m., officers arrived at the nursing home and walked through the front door where they saw patients crying and saying they had not received food or medication.

The officer also described the smell inside as “horrible.”

From there, Thomasville police, EMS officials and state investigators arrived and took over caring for the people inside.

It wasn’t until 2:30 p.m. on Jan. 17 that Pine Ridge had the proper staffing for the 98 patients.

The report also says administrators were in contact with each other from 7:35 a.m. on Jan. 16 until 9:53 a.m. when the administrator sent a text telling them to “hang in there. You all are a good team.”

On Jan. 17, the Pine Ridge administrator was suspended.

On Jan. 21, the director of nursing was suspended.

She admitted she was aware of the staffing issue and tried to call in staff but claims no one answered their phones.

She says staff members were just doing what they wanted to do and were leaving whenever they wanted to.

She said she had offered bonuses and a place to stay, and the only people who could stay were the two nursing assistants and the nurse, which was not sufficient staffing for 98 residents.

DHSR investigators say they found 13 areas at the nursing home that were deficient, and eight of them were serious enough to be cited at the immediate jeopardy level.

Noncompliance cited at the immediate jeopardy level is the most serious type of deficiency and carries the strictest sanctions. It also requires the provider to take immediate action to stop further harm.

Some of the areas cited are freedom from abuse, neglect and exploitation, quality of life and nursing services.

Pine Ridge has responded to the findings and has outlined a plan of correction. There will be a visit to see if the center is following the processes.

A spokesperson for the nursing home released the following statement on Monday night:

“The Covid-19 pandemic created unprecedented disruptions to the nation’s skilled nursing industry. Earlier this year, the rampant spread of the Omicron variant caused significant staffing shortages despite a high vaccination rate among staff members. Pine Ridge Health and Rehabilitation Center experienced a perfect storm of challenges one evening in January due to severe winter weather, the peak of Covid positive cases in North Carolina, and an increased reliance on contract agency staff.

“Pine Ridge has been working diligently to address issues that occurred on that day. We take the state’s concerns very seriously and are responding to areas identified by regulators. We are working diligently to take meaningful steps to ensure all residents are receiving the medical care and support they need. We remain focused on the safety and wellbeing of our residents and staff. We are also grateful as Pine Ridge has not had any positive employee cases since early February.”