In the last episode of this series, the author wrote about what citizens should do to choose a nursing home. He made the case that a search should use Medicare Compare to make a list of facilities in the vicinity of your search area and then use the Staffing rating to whittle it down to facilities with at least a three-star staffing rating. In some regions of Virginia, that doesn’t leave very many options, but so be it. Do not seek admission to an understaffed facility.

The November 20, 2025, the latest Provider Information was released by CMS. The attached spreadsheet contains key elements of that data for every Medicare- or Medicaid-certified Virginia facility. The author recommends that regulators use this format. It is color-coded to permit assessment of the state’s portfolio of facilities in a few minutes.

Now, a dive into it.

The data

Errors.

The first thing they must do is correct the errors in the CMS descriptive (vice statistical) data. The author has done that here. The blue text represents corrections. There are:

• Four changes to the provider name seen by the public. Princess Anne Health and Rehabilitation has lost its CMS certifications and no longer appears. The author added it back for reference.
• Seven changes to the Ownership type.
• Thirty-three updates to Chain Name, including five chains in Virginia that are unrecognized in CMS data. One is the six-month-old rebranding of Consulate Health Care to Avardis Health Care. The other four are “new” here, or at least new to CMS databases. That kind of error rate in chain names, duplicated across the country, frustrates any research to assess them without painstaking manual corrections. The worst chains consider that a feature, not a bug.

Stoplight fill colors are added by the author to allow a quick scan to absorb the important details. Red is worst. Dark green is best.

Provider Name. Provider names have the fill colors of the staffing rating. If sorted by city or county, the staffing ratings of the facilities in that area would be highlighted, allowing users to find facilities with at least average staffing.

Ownership Type. The author has sorted the data to show for-profit, government, and non-profit facilities and chains.

Average Occupancy. The author has used Excel to calculate the average occupancy rate from the number of beds and the average resident census. It is a very important percentage. It allows regulators to see at a glance which facilities are understaffed (2-stars) or much understaffed (1-star) and nearly full. If we scroll down to Lifeworks Rehab, we see a great deal of that.

Chain Name. Self-explanatory.

Staffing Rating. Staffing rating is calculated by CMS with a credible multi-variable algorithm based on six measures:

1. Case-mix adjusted total nursing hours per resident day (registered nurse (RN) + licensed practical nurse (LPN) + nurse aide hours) for a quarter averaged across all days (weekdays and weekends)
2. Case-mix adjusted RN hours per resident day for a quarter, averaged across all days (weekdays and weekends).
3. Case-mix adjusted total nursing hours per resident day (RN + LPN + nurse aide hours) for a quarter averaged across all weekend days (Saturdays and Sundays).
4. The percentage of nursing staff who left the nursing home over twelve months.
5. The percentage of RNs who left the nursing home over twelve months.
6. The number of administrators who left the nursing home over twelve months.

The source for reported staffing hours is the Payroll-Based Journal (PBJ) system. These data are submitted quarterly and are due 45 days after the end of each reporting period. Scroll down to the excellent Dogwood Village of Orange County Health and Rehab to see what happens when the data are submitted in error.

The spreadsheet is curated from Provider Information data so that regulators can associate chains with staffing ratings very quickly.

Nursing Case-Mix Index and Nursing Case-Mix Index Ratio.  

The nursing Case Mix Index (CMI) for a nursing facility represents the average of results of the facility assessments upon admission and quarterly of the needs of residents for support in both medical care and the activities of daily living.

The Case-Mix Index Ratio shows the effects of high CMIs upon the average Medicare and Medicaid per diems for those residents. A CMI ratio of 1.1 indicates the payments for residents average 10% higher than the nationwide average.

The CMIs and CMI ratios are color-coded tan and red to show the highest of Virginia’s ratios and thus the facilities getting paid the most.

Regulators can see at a glance how likely it is that understaffed facilities can provide the care that the government is paying for.

Number of Substantiated Complaints

This figure is the number of complaints in the past 3 years that resulted in a citation.

To write a citation, the state survey agency must visit the facility, review records, and interview staff and residents. The ability of VDH’s Office of Licensure and Certification (OLC) to do that has been constrained for years by massive understaffing at that agency. They have had to triage complaints based on perceived urgency. That problem is on track be solved by the end of this calendar year.

The National average is 29. The Virginia average under those constraints is 22.5. But, within the state, relative numbers among facilities are meaningful.

Resident and Family Council

Many residents are too frail or injured to speak for themselves. Regulators should insist that every nursing home in Virginia has both a resident council and a family council, except in very unique circumstances.

Bad chains

Ark Post-Acute Network, Avardis Health Care, Eastern Healthcare Group, Trio Healthcare, and YAD Healthcare facilities are understaffed at a rate that warrants a written warning to chain managers from VDH.

Ark Post Acute Network is a black box. It may operate only in Virginia. Eastern and Trio operate only in Virginia.

Some chains are quite reticent to expose the locations of their operations. Ark’s website does not inform readers of its locations. That is never a good sign. You can find locations through Eastern’s home page, only by:

• Clicking on Join Our Team
• Scrolling down to Job Opportunities, and
• Clicking on See All Cities.

Worse chains 

Lifeworks Rehab. Lifeworks Rehab’s

website, for some reason, lists only its facilities in Virginia and North Carolina, though it has acknowledged to CMS that it also operates in Delaware, Maryland, and Pennsylvania.

Lifeworks facilities in Virginia, seen through the multiple lenses of average occupancy, staffing rating, special focus status, CMI indices, and average number of complaints, are an ongoing scandal. The scandal seen in the data was manifest in multiple real-world scandals:

• Colonial Heights Rehabilitation and Nursing Center – raided and arrests made in December of 2024.  The charges so far include neglect, abuse, and wrongful death.
• Princess Anne Health and Rehabilitation Center was thrown out of federal insurance programs for bad patient care.
• Henrico Health and Rehabilitation Center is the Commonwealth’s only Special Focus Facility. That means it has been so bad for so long that it has no Medicare Compare ratings and is under special oversight by VDH.

With a portfolio of 37 facilities here, Lifeworks is the largest chain in Virginia. It may or may not be the worst chain in America. We’ll compare it to other bad ones nationally next time.

Marquis Health Services has owned seven facilities here for a long time. They are all understaffed. At the same time, each claims extraordinary levels of patient needs and thus Medicare and Medicaid payments.

Bottom Line

The owners and managers of Lifeworks Rehab and Marquis Health Services are still licensed to operate nursing homes in Virginia. We note that, in September 2025, Marquis was permitted to close on the purchase of seven additional nursing homes in the Commonwealth.