by James C. Sherlock

The featured graphic above and here is my attempt to produce an infographic without cartographer skills.  

It integrates a lot of information from different sources and internal calculations in an effort to show both:

1. how nursing home staffing in Virginia varies; and
2. how it has or has not complied with current federal minimum safe standards.  I have employed stoplight colors to indicate compliance or lack of same.

That picture tries to tell a complex and dangerous story.  

We will walk through it and see what we can learn.

Federal minimum staffing standards. In March of 2024, the Center for Medicare and Medicaid Services (CMS) published staffing requirements that were derived from a major study of staffing vs. patient outcomes. The requirements are described as the minimum for patient safety and health.

The featured image above incorporates those standards and shows how various Virginia nursing facilities that accept both Medicare and Medicaid have complied with them. The standards were established in a 2022 study. In 2024 they were published as regulations that are not yet in force, but they remain standards with which to measure staffing adequacy.

Facility choices. The focus is Medical Facilities of America’s (MFA) (same management as previously listed chain Innovative Healthcare Management) Colonial Heights Rehabilitation and Healthcare Center (Colonial Heights).  

Colonial Heights employees have been charged with  negligence and abuse in two pending cases:

• one for 19 members of the staff charged in the case of a woman who died in October of 2024; and
• the other for a doctor who is charged with neglect and abuse of another patient. 

The other facilities in the graphic — those controlled by MFA and those that are not — are chosen to offer a range of comparables and show both what is done and what is possible.  

I have purposely included MFA’s best-staffed facility out of its 37 in Virginia. Valley Rehabilitation & Nursing Center in Southwestern Virginia achieved a three-star (average) Medicare staffing rating. The other 36 have been awarded two stars (understaffed) or one star (much understaffed). I have put MFA’s best foot forward.

The spreadsheet. The spreadsheet was prepared from a combination of CMS Payroll-Based Journal (PBJ) Quarterly Nurse Staffing data and the insertion of formulas in the spreadsheet to calculate the values to compare against the CMS minimum standards.

The only column that represents current data is the CMS Staffing Rating. The rest of the data are from the calendar years and quarters noted.

To ensure that the graphic compares apples to apples,

• staffing of each of the facilities is presented in Q1 of 2024; and
• each accepts both Medicare and Medicaid.

It is coded in stoplight fill colors relative to the federal standards. Black cells are the worst in this group.

The first column provides data from which average occupancy rate can be calculated. We see that all of these facilities except for The Haven at Brandermill Run stayed pretty full. The others with poor staffing reflect business decision not to reduce patient load to relieve pressure on available staff.

The second column shows location. The last two facilities were added to the graphic to show that sufficient nurses were available for those two nursing homes in Chesterfield and Virginia Beach. But not enough were present at MFA’s Colonial Heights Rehabilitation and Healthcare Center (Colonial Heights) or Virginia Beach Healthcare and Rehab Center.

Huge personnel shortfalls. RNs and Certified Nurse Assistants (CNAs) are deemed by CMS to be irreplaceable in their duties to make patients safe and return them to health.

The RN and CNA staffing hours per resident per day (HPRD) in some of these facilities fall monumentally short of the minimum standards.  

Registered Nurses provide supervision, but they are also the only nurses who are licensed to provide much of the direct care to the highest acuity patients. The facilities report RN hours by their payroll designations as Director of Nursing, RNs with Administrative Roles and RN Direct Patient Care.  

The federal minimum safe standard for RN Direct Patient Care HPRD is 0.55. 

• MFA’s Parham Health and Rehabilitation Center in Henrico averaged 1/7th of that minimum in Q1 of last year.  
• MFA’s Colonial Heights offered 1/5th of the minimum number necessary.
• There are nine facilities profiled. Only the bottom three are non-profit. The one with the highest RN Direct Care HPRD was for-profit August Healthcare at Iliff.

Certified Nurse Assistant. The federal minimum safe standard for CNA HPRD is 2.45.  Some of the MFA facilities met less than half of that requirement.  

CNAs provide a wide range of critical assistance to patients. Their numbers are a broad issue in the industry. The three non-profit facilities solved it by paying sufficient numbers of people to train with them at their facilities to attain CNA status and retaining them once qualified.

Total Nurse Staffing is a separate category in the federal standards, meaning the minimums for RN and CNA must be met, but minimum  Total Nurse Staffing, 3.48 hours must also be met. That category permits Licensed Practical Nurses (LPN) to be counted.  

Parham had a decent number of LPNs but was so low on RNs and CNAs that it still missed the cut by a full hour of total nurse HPRD. 

Nurse Turnover Rates and location. Personnel turnover rates in any business reflect a combination of leadership, workplace conditions, business culture and opportunities for alternate employment.  

The contrasts between nursing staff turnover rates in the facilities in Chesterfield and Virginia Beach are particularly informative.  

Smyth County is in the Appalachian foothills along I-81. It and Bristol City are the two Southwest Virginia locations in this graphic. RN turnover rates are generally lower in that part of the State than elsewhere.  

Reflecting the relative wealth and preference for home care of its citizens, Northern Virginia has a far lower market penetration of nursing homes relative to population than the rest of the state. The nursing homes there as a group are better rated across the board than elsewhere in the Commonwealth. 

Even so, for-profit August at Iliff in Fairfax County has done a terrific job at retention.  

Next. Non-nurse staffing includes physicians, Advanced Practice Registered Nurses (APRN), dietitians, pharmacists and other key staff. We will look at that for these same facilities in these same calendar year quarters in the next article in this series.

Then we will examine the patient outcomes to see if and how staffing measurably matters.

Spoiler alert: It does.