Cutting the Gordian Knot
by James C. Sherlock
An overarching fact often overlooked is that the for-profit nursing home industry is the creation of Medicare and Medicaid. Few for-profit facilities and chains existed before the passage of those programs in 1965. Yet it is for-profit systems that overwhelmingly commit abuses.
Government oversight has proven an abject failure across much of the country and certainly here.
In Virginia, in what started in October of 2024 as a police investigation of reported elder abuse, the Administrator and the Director of Nursing at Colonial Heights Rehabilitation and Nursing Center (Colonial Heights) were arrested in December of 2024 along with 16 other employees. They were joined on the docket in January of 2025 with the arrest of the facility Medical Director.
Police allege that a 74-year-old patient with cerebral palsy and diabetes was maltreated at the facility that resulted in her death. Among the charges are felony neglect and abuse, falsification of records and obstruction of justice.
The government alleges a sequence of events truncated below:
- she was admitted to Colonial Heights;
- she suffered a pressure ulcer caused by not being repositioned in her bed by nurse assistants;
- the ulcer was not properly treated;
- she was readmitted to a hospital;
- she was diagnosed there with sepsis acquired at Colonial Heights; and
- died as a consequence.
That exact sequence, assuming it happened that way, was predictable from government records.
Colonial Heights’ score on quality measure S_039_01: Percentage of infections patients got during their SNF stay that resulted in hospitalization during the period Oct. 1, 2022 to Sept. 30, 2023 was 15.38%. Nearly one in every six Medicare patients was re-hospitalized for infections acquired at Colonial Heights. Innovative Healthcare Management (now Lifeworks Rehab) was in charge during the entire grading period. That performance is noted in the record as “worse than the National Rate.” In government-speak, that means bottom 10% nationally.
That is hardly the only notice of danger the government had. They knew the facility remained grossly understaffed and very crowded.
VDH’s inspectors – nurses and other professionals:
- report regularly and cite in detail abuses of helpless people. Their observations are called citations for a reason. The facilities are cited for violations of specific federal laws and regulations.
- The facilities then promise never to do it again. Case closed.
- Until the next serious patient complaint or routine inspection.
- When the facility is cited again and again promises to reform. The state accepts those assurances without even a revisit to check.
That passes for oversight here.
Those inspectors conducted a complaint inspection of Colonial Heights that was in progress on the day of the police raid. The resulting report of deficiencies is 341 pages long. Every word of it details federal law and regulation violations.
Colonial Heights isn’t even the chain’s worst facility in Virginia. That honor goes to Special Focus Facility Henrico Health & Rehabilitation Center, the worst nursing home in the state.
Nothing effective was done by the owners of Colonial Heights to fix the well-documented problems before that woman’s death. The government proved helpless to stop it. It remains so.
I think I may have landed upon a solution that will work. (more…)
