by James C. Sherlock

This article was revised on November 16 to provide a better view of the data.  The format the author chose wasn’t getting the job done, so he revised it.  Changes in the text are made only to reflect the updated spreadsheet.  It should provide more clarity.

This is the third article in a sub-series on nursing homes sorted by region in Virginia. The regional classifications correspond to the ones used by the Virginia Department of Health.

The comments on each region will focus on staffing because of its paramount importance, but the data offer much more information. The first article was about the Eastern Region, the second about the Central. This one is about Virginia’s Southwest.  

Readers may use this article to contact their General Assembly members, members of the House of Representatives, and United States Senators with their own comments. These five columns are designed to be forwarded. If a reader thinks their representative would benefit from another article in the broader series to make their point, send them that one too. The author recommends consideration of this one about the scheme being run here by the worst chains. They are public record.

Color coding. The color coding makes the data relatively easy to scan. Red is worst. Tan is next, then white, then light green. Dark green is best.

National Averages. National averages for each of the measures in the regional spreadsheets are noted in the header row. The minimum safe staffing standards for patient safety established for the Center for Medicare and Medicaid Services (CMS) by the National Academy of Medicine are noted in that same row. Southwestern Region facilities lag those averages and standards in nearly every measure.

Errors in data. The data reflect what chains and independent nursing homes report to CMS. Unsurprisingly, the worst chains have a bad track record in their reporting. I have corrected the errors.

Staffing. The comments on each region will focus on staffing because of its paramount importance, but the data offer much more information.

Case-mix indices. The case-mix index data are compiled from assessments by the nursing home staff of new residents upon admission.  Higher numbers are supposed to indicate patients who need relatively more assistance with health care and activities of daily living. The higher the number, the higher are Medicare and Medicaid payments. Some reflect much higher average CMIs than the national and state averages. In an isolated case of a single facility, that may prove justified briefly. As a trend for all of the facilities of a chain, it is something else.

Rating Cycle 1 Health Inspection Dates. Health inspection surveys are supposed to happen every 12-15 months. Virginia’s inspectors, as in every state, carry out those federal inspections in conjunction with state licensing inspections.  

As reflected in the Rating Cycle 1 (latest) inspection dates recorded in CMS data, Virginia has not come close to meeting those standards. Virginia’s inspection teams have been grossly understaffed for more than four decades. That has finally been fixed at the request of Governor Youngkin by changes to the law and appropriations in 2025. The new inspectors have been recruited, hired, and are being trained now.

On to the Southwestern Region.

Southwestern Region
The spreadsheet linked above is designed to be self-explanatory. The sums and averages line at the bottom shows regional results.

The Southwest Region is normal for the state in staffing and Case-Mix Index, but absolutely remarkable in its Inspection Ratings.  On average, they far exceed those of the rest of the state.  As if in confirmation, they also have the fewest average number of complaints that result in a citation.  They train more of their own nurse aides than any other region.  

Overall, the Southwest region demonstrates the results of outstanding work cultures within the buildings.  

There are 85 nursing homes in the Southwest Region. They have a total of 9,428 beds. Average occupancy 86.3%

Occupancy vs. Staffing in the Southwestern Region.  

Roanoke, still the capital of the nursing home industry in Virginia, has twelve of the 87 facilities in the region. Lynchburg hosts eight. Danville four. The rest are spread around, many in groupings of three in the smaller cities and in Allegany, Botetourt, Smyth, Tazewell, and Wise counties.    

Forty-nine of the 85 facilities, with 65% of the total beds, are rated by Medicare Compare as either:

• much understaffed – one star (25 with 31% of the beds) or
• understaffed – two stars (24 with 34% of the beds).

Occupancy rates are the inverse of what a properly functioning market would produce if consumers used the data available in Medicare Compare. Hospitals in particular should ensure they have it.

• The one-star staffed facilities averaged 88% occupancy.
• The occupancy rate in the 24 facilities rated understaffed (2 stars) was 85%
• The twelve four-star-staffed facilities in the Southwestern Region have a combined xx beds and still only average 84% occupancy. They are anchored by some of Virginia’s largest facilities: Roanoke’s two Friendship Health and Rehab Centers have a combined 370 beds and average 93% occupancy, and Virginia’s largest nursing home, the 312-bed Roman Eagle Rehabilitation and Health Care Center, is in Danville.  t reported 72% occupancy.    
• The best of them — the nine five-star staffed facilities — are typical of that category statewide. Among them, they have only 429 beds and average 61% occupancy. With some overlap of designation, they include
• • three community hospitals;  
  • a specialized state government facility; 
  • two long-term-care-only facilities;
  • three church-related facilities; and
  • a Westminster Canterbury senior living complex.  

Across the state, generally speaking, the worse-staffed the facility, the higher the occupancy.  

The hospitals bear some responsibility for that. So do the insurance companies, including Medicare Advantage and Medicaid, who are supposed to look out for the welfare of their members. But nursing home administrators are required by federal law and regulations to maintain adequate staffing by assessing the facility’s capabilities and controlling the admission of new residents to stay within them. Few do it.  

Most who work for the chains would lose their jobs if they did.

For-profit out-of-state chains plague the Commonwealth 

Chains headquartered in other states, especially New Jersey, are together responsible for the shortfalls in the average performance of nursing homes across the state.  If they performed to national norms, so would Virginia’s portfolio of facilities.

Recommendations

Recommendations for federal and state actions have been offered throughout this series.  Readers can link to them in communications with their representatives at the state and federal levels.