by  James C. Sherlock

In a recent 12-month period overlapping 2022 and 2023, almost 8,400 Medicare patients alone were admitted to a hospital directly from or within 30 days after discharge from one of Virginia’s 280+ skilled nursing facilities.

We simply do not know how many eventually died as a proximate outcome of poor care in those facilities.

But we can examine some of the human costs.

A death in Chesterfield County.  In late October of 2024, a Chesterfield County woman is alleged by the Commonwealth’s Attorney to have suffered horribly and died from an infection she acquired at Colonial Heights Rehabilitation and Healthcare Center (Colonial Heights).

“Those arrested included multiple nurses and the charges include felony abuse and neglect of vulnerable adults, falsifying patient records, and obstruction of justice.”

The charges include criminal abuse and neglect of a vulnerable adult resulting in serious bodily injury or disease.  The allegations in this case include:

• Victim was left in her bed for days in her own urine and feces, not turned or changed, resulting in severe flesh wounds.
• The wounds were so severe that they allegedly caused sepsis, which ultimately led to the patient’s death.
• The patient’s foot was reportedly broken, and
• She was given incorrect medicine that “poisoned” her.

Some are further charged with falsification of records and obstructing justice to cover it up.  

Now a 19th staffer has been arrested and charged with felony abuse.

In a separate case, a physician was arrested two weeks ago in connection with the death of another Colonial Heights patient.

All of those arrested, by working in an “administrative, supportive or direct care capacity” in that nursing home, were mandated reporters of suspected abuse, neglect or exploitation of aged or incapacitated adults.  We do not know if any made the required reports in this case or any other.  

Systemic problems pre-dated by years the employment of some of the people arrested. Circumstances hauntingly similar to the neglect alleged in this case were reported pursuant to a state complaint inspection in 2021.

But after all of this, a check with Colonial Heights admissions about a week ago revealed that it was accepting new patients.

Thus motivated, I offer here a broad background for the evidence in the case.

SNFs love Medicare patients.  A recent study found:

“spending on postacute care was significantly greater in Medicare than in commercial insurance for clinically similar well-insured people around age sixty-five…. Despite increased spending on postacute care in Medicare, there were no significant differences in readmission rates to suggest clinical benefit.” 

Medicare paid Colonial Heights 19% above that already generous average payment for the self-reported acuity of its patients.  Its latest staffing record shows major shortfalls.  

Combine the two, and you understand Colonial Heights’ extraordinary profit history.

Colonial Heights quality reporting. We will note two measures of hospitalizations from the latest Colonial Heights record from the Skilled Nursing Facility Quality Reporting Program (SNF QRP). 

In the most recently-reported 12-month period, 63 patients connected to Colonial Heights were hospitalized for one of two outcomes:  

1. infections patients got during their SNF stay that resulted in hospitalization; or 
2. potentially preventable hospital readmissions 30 days after discharge from a SNF . 

Both were among the worst in the nation.

That facility also reported far worse results than the national averages and in the following additional categories:

1. Rate of successful return to home or community from a SNF;
2. Medicare Spending per Beneficiary (source of statement above that Colonial Heights was 19% higher);
3. Percentage of residents who are at or above an expected ability to care for themselves at discharge;
4. Percentage of residents who are at or above an expected ability to move around at discharge;
5. Percentage of residents with pressure ulcers/pressure injuries that are new or worsened;
6. Percentage of SNF healthcare personnel who are up to date with their COVID-19 vaccines;
7. Percentage of healthcare personnel who got a flu shot for the current season; and
8. Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge

That represents nearly a clean sweep of dreadful performances.

Infection rates in Virginia. CMS believes that lower SNF Healthcare-Associated Infections (HAI) scores indicate better quality of care for Medicare patients.

There are two rates:

• the actual rate, which is the rate at which patients go to the hospital, and
• the risk-standardized rate, which accounts for patient acuity and is the figure for which the SNF is accountable to CMS.

The highest in Virginia of both actual and risk-standardized rates were found at six facilities.  They are listed with their actual (observed) Medicare patient hospitalizations and rates:

• Bayside Health & Rehabilitation Center in Virginia Beach – 25 / 12.8%;
• Pulaski Health & Rehab Center – 24 patients – observed rate 13.5%;
• Radford Health And Rehab Center – 28 infection hospitalizations – 13.2%;
• Westminster At Lake Ridge – 27 patients – 12.7%;
• Colonial Heights Rehabilitation And Nursing Center – 26 patients – 15.4%
• Westmoreland Rehabilitation & Healthcare Center in Colonial Beach – 14 patients – 17.5%.

The infection hospitalization data for every SNF in Virginia can be seen here.

How many SNF patients hospitalized statewide?  In a single 12-month period ending September 30, 2023 (latest available), QRP data  show that

• over 2,300 patients were admitted to hospitals directly from SNFs for infections acquired there; and  
• 6,084 more suffered potentially preventable hospital readmissions 30 days after discharge from a SNF.

The SNF QRP is applied only to Medicare Part A covered SNF stays. So, there were higher numbers of hospital admissions from SNFs than reported here.

Who reported elder abuse? A lot of people were mandated by Virginia law to report the crimes alleged at Colonial Heights.  That list includes but is not limited to:

1. Any person licensed, certified, or registered by health regulatory boards listed in § 54.1-2503, with the exception of persons licensed by the Board of Veterinary Medicine;

5. Any person employed by or contracted with a public or private agency or facility and working with adults in an administrative, supportive or direct care capacity.

There are a lot of people in those categories who worked at or were contracted to visit patients at Colonial Heights, including Medicaid managed care contractors.  

The only ones charged so far are the local staff.

Charging staff with crimes. I will pause here and plead the case for the professionals working at very understaffed nursing facilities. The work is very challenging, and we are lucky to get people to do it.

Indeed, some owners plead that there simply are not enough workers out there to staff their facilities.

First, that claim is belied by the stratospheric nurse turnover rates at the worst of them. It is clear that if that group had retained a higher percentage of staff, the shortfalls would have been ameliorated and there would have been a higher level of institutional memory about, well, everything.

The best SNFs have turnover rates that reflect the normal ebb and flow of people’s lives. Colonial Heights had a registered nurse turnover rate of 89% in the year ending November 1 of 2024. The total nurse staffing turnover there was 71%.  

No business, much less one that treats very sick and injured patients, can be run efficiently and effectively under such conditions.

Second, owners can reduce the patient load to match available staff by stopping admissions. Some do, but not Colonial Heights, nor at any controlled by the New Jersey-based for-profit chains discussed earlier in this series. Colonial Heights ran at 92% of average capacity.

Third, Colonial Heights’ Medicare one-star staffing rating does not fully express the problem.

Registered nurses supervise medical care for all patients and provide it directly to patients for procedures for which only they are licensed.

Nurse aides among many other duties support helpless patients like the dead 74-year-old woman.  She suffered from cerebral palsy and diabetes.  Their duties would have included turning her in bed to avoid pressure ulcers, helping her with bathroom needs, cleansing and showering her, and applying medicine to her skin.

The federal minimum safe staffing standard for RNs is .55 hours per patient per day (HPRD). At Colonial Heights, the actual staffing was 0.30 HPRD, 0.19 on weekends.

The associated standard for nurse aide staffing is 2.45 HPRD . Colonial Heights self-reported that it averaged 1.54.

The defense will make and a jury will get the point.  

What to do?  

We are obsessing, as people do and should, on one patient who allegedly died because of abuse and neglect at one SNF.  

The federal government has the power to stop the worst of this. Always has.  So relying on CMS does not seem to be a plan.  

But the Commonwealth has a well-defined public health problem.  The data on re-hospitalization of patients directly from or within 30 days after SNF discharge in Virginia are absolutely staggering.  Statistically it is nearly impossible that only a single Virginia death was attributable to SNF abuse or neglect among the 8,384 patients with SNF-associated hospitalizations.  

And those were just the Medicare patients.

We have shown in this series of reports that problem is systemic in the worst-staffed chains and centered there because of the large number of facilities they control.    

The rules are clear.  Daily nurse hours per patient is a ratio. The denominator is number of patients.  Higher ratios are better.  There are published federal minima.  

Chain managers and facility owners can at any time mitigate patient risks and staff workloads by voluntarily halting the acceptance of new patients in their facilities until sufficient staff is available to provide for their health and safety.  A few have done so.  Most have not.   

The names of the chains are ephemeral.  Virginia must ban the individuals most responsible from owning and operating SNFs in the Commonwealth.  .

They do not work in any single facility, but rather are chain managers and facility owners who we have identified in this series to

• have targeted Virginia; and
• demonstrably understaff as a business model.