On 29 October of 2024 a woman died under tragic circumstances in Virginia.  Her death was preceded by suffering that mercifully we cannot fully imagine.

The government alleges that she died as a result of neglect at Innovative Healthcare Management’s (IHM) Colonial Heights Rehabilitation and Nursing Center (CHRNC) in Chesterfield County.

The best summary report of her case that I have seen to date is here. The article, available to nurse.org’s >1.5 million monthly readers, discusses key details of the case and broader implications for nurses and elder care. The case has created an online firestorm among nurses.

I will summarize it below. Quotations are from the article.

Summary of events. The circumstances leading to the woman’s death are being investigated by Colonial Heights Police in coordination with Attorney General Miyares’ Medicaid Fraud Control Unit (investigates elder abuse in Virginia), the Virginia Department of Health and the Chesterfield Commonwealth Attorney’s office.

On December 18, investigators arrested five individuals and issued warrants for 13 others, all CHRNC staff.

Charges so far include seven counts of felony abuse and neglect of a vulnerable adult, two counts of misdemeanor abuse and neglect of a vulnerable adult, two counts of obstruction, and 27 counts of falsifying patient records.

On December 19, 2024 Noelle Nochisaki, a prosecutor representing the Commonwealth Attorney, alleged in Chesterfield General District Court that a 74-year-old woman with cerebral palsy and diabetes:

• was left in her bed in CHNRC for days in her own urine and feces, not turned or changed, resulting in severe flesh wounds;
• the wounds were so severe that they caused sepsis.
• she was admitted to the hospital, where the infection resulted in her death.

She continued:
… the victim’s foot was broken at some point, and she was given incorrect medicine that “poisoned” her, and instead of reporting the incident and having her transported to the hospital, staff just observed her.

The prosecutor then told Judge James O’Connell:

… her wounds from the poor care were so bad that Adult Protective Services originally thought she may have been the victim of a sexual assault. That was not the case, though the flesh wounds to the patient’s genital region were so bad, they were described as necrotic.

Underscoring the seriousness of the allegations, at least two supervisors were initially denied bail.

Recent history of Colonial Heights Rehabilitation and Nursing Center. An attachment from an article I published in early October of 2021 showed CHNRC sporting the lowest possible ranking by Medicare in overall performance, in staffing and in health inspection results.

Today, more than three years later, that facility retains all three of those lowest possible rankings.

One thing that owners completely control is patient load, the denominator of the hours per resident per day (HPRD) fraction that is how federal staffing standards are expressed.  Finalized in April of 2024, enforcement of those standards as regulations will be phased in, but they are medically valid now.

CHNRC had about 175 patients daily, an identical 92% occupancy rate, both in Q2 of 2021 and in Q2 of 2024.  CHNRC’s self-reported staffing ratios declined over that period.

• Total nurse staffing hours per resident per day (HPRD) dropped from 3.05 in 2021 to 2.76 at last report in 2024.  Most of that decline was in certified nursing assistants (CNAs). Why? One answer: in Q4 of 2022 CHNRC hired people to train as CNAs. They stopped the practice at the beginning of 2023.
• The federal minimum standard for patient health and safety for total nurse staffing is 3.48 HPRD. CHNRC missed that standard in their latest report by 20%;
• CHNRC reported RN staffing in the 2021 data at .31 HPRD. In 2024 .30 HPRD. The federal minimum standard is .55 RN HPRD. CHNRC missed the minimum RN HPRD by 45%.

So CHNRC owners in Q2 of 2024:

• understood the long-predicted federal staffing standard,
• knew they did not come close to meeting it,
• had complete control of occupancy, and
• kept it as full as possible.

That was a business decision.

But a convincing case can be made that a more manageable patient load would have increased staff nurse retention. RN turnover was nearly 90% at CHNRC in the past year – twice the national average. Total nursing staff turnover was 71%.

I assessed the Q2 2024 staffing of all of 291 certified and licensed nursing facilities in Virginia.  The worst are here.  CHNRC was among the bottom 5% in the Commonwealth.  Because Virginia is a bottom feeder in nursing home staffing nationally, CHNRC’s place among the worst-ranked and worst-staffed facilities in America was secure.

Yet it remains both certified for Medicare and Medicaid patients and licensed by the state of Virginia.

I spoke yesterday with the facility’s admissions office.

It is accepting new patients.

Commentary. It is likely that grossly understaffed nursing facilities will get worse after the nurse.org article and local reporting led by CBS 6.  They can anticipate a surge in nursing staff resignations and may find the gaps nearly impossible to fill.

As for the Colonial Heights facility, news reports have indicated that the owners have replaced the 18 indicted staffers with personnel from other IHM facilities, all of which are in Virginia. Since every other IHM facility was ranked as understaffed before the arrests, it seems prudent that VDH immediately check the sufficiency of the staffs of all of them.

Those checks should include nearby Wonder City Rehabilitation and Nursing Center in Hopewell.  It was very recently transferred from IHM to Medical Facilities of America (MFA). MFA shares investors with IHM. The transfer was so recent that Center for Medicare and Medicaid Services (CMS) records still reflect IHM ownership.

See here and scroll to the bottom to see how those two chains and three others that, like them, operate in Virginia only or in Virginia and North Carolina only, rank nationally in staffing.

Bottom line. Colonial Heights Rehabilitation and Nursing Center is but the tip of a very large iceberg.

As a long-time investigative reporter on the dreadful state of too many of Virginia’s nursing homes, I will offer additional facts I think relevant to this case in a series of articles of which this is the first.

The responsibility for caring for the health and safety of that woman lay primarily with CNRNC staff and owners. No word yet on indictments of the owners.

But there were a lot of others charged with reporting and oversight that failed to protect her.