by James C. Sherlock

The government alleges that a woman patient helpless with cerebral palsy and diabetes was so badly neglected at Colonial Heights Rehabilitation and Nursing Center (CHRNC) that:

• she died in late October last year after prolonged suffering from sepsis as a result of that maltreatment; and
• criminal charges have been filed against 18 members of CHNRC staff.

It is important for justice to be fully served to peel back the onion — to address the system in which they worked.   

CHNRC is operated by the private-equity-owned chain Innovative Healthcare Management (IHM), one of two sister firms with interlocking management and investors.

• IHM, with five facilities, operates in Virginia only. It closed on its first facility, CHRNC, on December 1, 2019 and the rest on Jan 1 of 2020. IHM’s office is in Richmond; and
• IHM’s sister chain Medical Facilities of America (MFA) operates 30 facilities in Virginia and eight in North Carolina. It closed on its first facility, Fairfax Rehabilitation and Nursing Center, on October 31 of 2020. MFA’s office is in Roanoke.

Please open the linked spreadsheet. It contains Center for Medicare and Medicaid Services (CMS) provider information curated to present all 35 IHM and MFA facilities. 

For reference to scale, Virginia has 291 nursing facilities certified for Medicare and Medicaid, North Carolina 419.

The first item of note in the spreadsheet is average occupancy calculated for this report. Most of those 43 facilities were run at near (or beyond) certified capacity. CHNRC’s 92% average occupancy (national average 80%) indicates the chains’ leadership, with full control of patient admissions, chose not to cut back in any significant way to match patient care needs with available staff.

Most Recent Health Inspection More Than 2 Years Ago raises a key issue. Note that all such facilities in the spreadsheet are in Virginia. 

The Virginia Department of Health (VDH) Office of Licensing and Certification (OLC) combines and conducts both full Medicare and Medicaid certification health surveys for CMS and state licensing inspections. It is required to do so annually. But it cannot due to its own major staffing constraints. Nearly half of the positions on the regional inspector teams are unfilled.  

The last full survey and inspection was conducted at Colonial Heights on 10-28-2022.  

OLC also investigates complaints. In accordance with CMS policy, it inspects quickly for severe allegations; otherwise it does so with batches of complaints gathered over time. The “revisits” listed are done by phone.

Medicare star ratings represent a five-star rating system. Here is the Medicare nursing facility online patient guide “Medicare Compare” filtered for Virginia facilities. Colonial Heights Rehabilitation and Nursing Center is not where you would choose to stay if you used that guide.  

You would be right.  

But most people depend on referrals from hospitals, assisted living facilities or friends. That often proves a bad idea. More on referrals and transfers in another part.

The overall rating is compiled with an algorithm dominated by health inspection results.

Health inspection ratings and thus overall ratings are compiled in a Bell curve for each state. That is done to adjust for significant state differences in inspection assessment results even though each uses the same State Operations Manual. It also means that, with a significant lag in inspections as in Virginia, the overall rating may not be useful for assessing current conditions.

Quality Measure (QM) ratings are compiled from facility reports. Some measures of patient health in those reports are subjective and thus are subject to manipulation. They are quite often significantly higher than other rankings for the same facility, and can raise the overall rating. CMS is working to fix that.

Staffing star ratings are based upon the quarterly reports of daily staffing of critical job codes that are linked to CMS-specified payroll codes. That makes them subject to audit. With that national standardization, they are compiled using a Bell curve for the entire nation’s nearly 15,000 certified nursing facilities.  

Staffing star ratings usually represent the most current facility data and are very important when choosing a facility.

MFA and IHM with 43 facilities total have only one at the national average for staffing. The rest are below (2 stars) or much below (1 star) average. Since many facilities in both states have 4- and 5-star staffing ratings, some might conclude that IHM and MFA understaff as a business model.

Minimum staffing standards. CMS has established minimum staffing standards for ensuring patient safety & health with which I have annotated the spreadsheet. 

Staffing in LTC facilities has remained a persistent concern, especially among low-performing facilities that are at most risk for providing unsafe care. CMS believes that national minimum nurse staffing standards in LTC facilities, the adoption of a 24/7 RN requirement, and enhanced facility assessment requirement … are necessary … to protect resident health and safety and ensure their needs are met. (emphasis added)

The patient death from alleged neglect at CHRNC in October of 2024 is haunting reminder of the truth of that warning.

The standards were derived from a 2022 staffing study commissioned by CMS. The standards were finalized in April of 2024 as regulations under the Social Security Act. They will be phased in over several years. Even if the regulations are repealed, the standards will remain as legal evidence of sufficient or insufficient staffing.

Staffing hour data columns are sourced from the payroll-based quarterly reports of daily staffing submitted by the facilities, usually by their chain headquarters. 

• red fill indicates staffing below those standards,
• yellow numbers represent well below, and
• yellow numbers with yellow cell borders are the worst.

Staff hours per resident per day (HPRD) in this particular data set are quarterly averages. We will use another data set in a later article to show how bad things got on some days.

Using that visualization, several things jump out.

Colonial Heights Rehabilitation and Nursing Center is perhaps the worst-staffed facility among even this sorry lot, establishing it firmly as one of the worst-staffed nursing facilities in the nation. At 92% average occupancy, no apparent effort was made to reduce patient load to improve patient care and safety.

Nursing staff turnover is appalling. No organization can run effectively like that. No administrator left in the previous 12 months. The obvious question: “why not?”

Facility-reported incidents. There was not a single nursing facility incident reported in the Commonwealth the entire state in the pervious 12 months at the time of this report. Not one. As you can see, things are different in North Carolina.  

Virginia clearly must review its standards for reporting. The term “major” incident in the regulation is not defined. So no reports are made. The Board of Health is responsible for that wording. Mystery solved.

A dreadful inspection. Penalties appear from their timing in early 2022 to have resulted from a report of an unannounced November 16-17, 2021 complaints inspection. The survey team conducted a facility walkthrough and reviewed complaints primarily from the caregivers of 13 residents.

Findings of that 41-page complaint inspection report include:

• verbal abuse of a patient who suffered from aphasia and stroke;
• failed to immediately notify physician and resident representative of a patient falls for 2 of the 13 residents. Resident #1 suffered a fall. Resident #3 suffered a broken femur;
• failed to maintain an accurate clinical assessment for Resident #1;
• failed to develop and implement a comprehensive care plan that included fall risk for Resident #1;
• broken furniture;
• food-encrusted wheelchairs;
• the 100-resident unit identified as the Tyler unit was noted to not be maintained in a clean and sanitary manner. Rooms were filthy. Only one housekeeper for entire wing. “The department manager/Employee D schedules for rooms to be deep cleaned but they don’t have time to do it”;
• ample evidence of cockroach infestations;
• significant infrastructure issues in need of repair;
• failure to administer prescribed pharmaceuticals. Waited a week after requested for the administrator to sign for a prescription that exceeded “facility’s High Dollar threshold”; and
• staff failed to provide assistance with activities of daily living (showers and others) for four Residents (Resident #2, #7, #8, and #10) in a survey sample of 13.

On 11/17/21 at 10:06 AM, an interview was conducted with CNA C. When asked about the frequency of showers CNA C said, “Once a month and twice if they get lucky”. We don’t have time, with our work load so heavy we are assigned anywhere from 12-20 Residents a day”.  

Notably, each resident under the CMS standard is required to get a minimum of 2.48 hours of nurse aide support each day.  

The financial return for understaffing is off the charts.

Penalties imposed on CHRNC for the past three years are ridiculously low given its abysmal performance: $13,944 in fines and a single eight-day new patient payment denial. One RN costs at least $100k a year all in.

• American nursing homes operated at an average operating margin of -0.4% in 2022.  
• The operating margin for CHRNC was +17.5% in 2022, +20% the year before.  

So greed works, just not for patients.  

Other for-profit chains find enough staff and make money, just not nearly that much. But who would want to work at CHNRC? Staffing shortages become at some point a self-reinforcing.

Bottom line. CHRNC is probably not where you would send mom if you had that information, but such facilities have contracts with hospitals which do just that nearly every day. It is accepting new patients.

Use Medicare Compare when searching for a nursing facility, with particular attention to staffing. When you open the file for a particular facility of interest, scroll down to staffing and click on “View Staffing Information.” You get this. That is the level of information you need.

Perhaps those investigating the horrible death of that woman will see a pattern in this evidence.

Perhaps the indicted employees are not the only culprits. There will be more to choose from in the next Part.