by James C. Sherlock

Disclaimer. The author is a member of the Virginia Nursing Home Oversight and Accountability Advisory Board established under Governor Youngkin’s Executive Order 52.  Nothing in this series should be taken to represent the opinions of the Commonwealth or that Board.

This series will explore the dreadful and dangerous choices faced by many who seek nursing homes in Virginia. It will illuminate those choices in various regions of the state in consecutive articles.

Too many facilities should be avoided, but there are simply not enough decent choices in many areas to support local nursing home demand. Those choices and competition generally are limited purposely by Virginia’s Certificate of Public Need (COPN) law.

For years I have offered testimony in this space based upon excellent Virginia Department of Health (VDH) reports of inspections. Many describe terrible conditions and the resulting human tragedies. Those conditions are cited by VDH inspectors in the reports as violations of the federal Social Security Act and federal regulations for its enforcement. Virginia law and regulations for nursing homes are in every case less demanding than federal counterparts, so are in practice useless. Federal money and therefore federal supremacy are involved.

The widespread negative publicity generated by the results of the December 2024 raid on Colonial Heights Rehabilitation and Nursing Center raised public awareness of the problem. That in turn resulted in the 2025 General Assembly passing decades-needed additional regulatory authority and funding for hiring of additional inspectors by the Virginia Department of Health (VDH).

The highly accelerating trend of individual complaints to VDH on nursing homes is another result of that publicity. Both are welcome.

The dilemma for Virginians is posed mostly by out-of-state for-profit chains whose breakneck growth since early 2000 has led to their dominance in many geographic areas. That growth continued with the closing in September 2025 on the purchase of seven nursing facilities from Newport News-based Virginia Health Services (VHS) by Brick, New Jersey-based Marquis Health Services.

Rapid discharges of patients from hospitals to skilled nursing beds are driven by government and private insurers to lower the total cost of treatment. That treatment is underwritten by Medicare. That policy makes good sense as policy.  It bends the overall insurance cost curve downwards.

The long-term care beds are paid for primarily by Medicaid reimbursements.

The unwritten assumption of government policies is that there are sufficient capably staffed beds to accept them. That assumption is demonstrably untrue in many communities in Virginia and elsewhere.

The methodology described below will be used in this series for assessment of the options for seekers of nursing homes in several Virginia locations.

Assessing the data

I have a decade of experience assessing federal Center for Medicare and Medicaid Services (CMS) data in a couple of dozen states. The reporting in this series is based on personal observations informed by that experience.

For a first look, I will report here data that are both meaningful and relatively hard to manipulate. I will begin with two of the Medicare Compare Five Star ratings.  

Medicare Compare Codes:

• 1 star = much below average
• 2 stars = below average
• 3 stars = average
• 4 stars = above average
• 5 stars = much above average

a. Inspection rating. The most accurate measure of performance is derived from inspection reports and substantiated findings from complaint investigations. The rating star number is established from a Bell curve of the results among Virginia facilities;

b. Staffing rating. This is relatively hard to manipulate because it is based upon payroll data from each facility. The payroll systems are all standardized to CMS requirements and are thus auditable. CMS bases facility staffing ratings on two components of those reports:

1. registered nurse (RN) hours per resident day; and
2. total staffing hours (RN+ licensed practical nurse (LPN) + nurse aide hours) per resident day. The staffing measures are case-mix adjusted for different levels of resident care needs.

The staffing star rating is established from a national Bell curve.

To those I will add:

c. number of beds average occupancy rates calculated from data on beds and average occupancy;

d.  total nursing staff turnover and RN turnover.  I find these numbers extremely useful.  Very high turnover makes a negative statement.

Both Case Mix Index (CMI) and Quality Measures (QM) are calculated directly from nursing home inputs that are in many cases not credible. Both use data from the Minimum Data Set (MDS), which each nursing home submits for each resident as part of a federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified facilities. That evaluation brings the potential for manipulation.

• CMI is the golden data point. It determines how much Medicare and Medicaid pay in per diem in a capitated system — higher CMI results in higher reimbursements. I will report it not for its accuracy but to assess how chain facilities are reporting that figure. Anomalies such as consistently high CMIs across a chain tend to jump off of the page; and
• A 5-star Quality Measures (QM) rating can raise Overall star rating no matter a facility’s annual survey and complaint inspection rating. It is not at all uncommon, and utterly consistent in some chains, to see facilities with 1-star inspection and staffing ratings and 5-star QM scores. I have seen it so often that I will not use or report QM scores.
• CMS uses QM data along with inspection results and staffing in calculating Overall rating. So, I will not report Overall rating either.  

I will not report Quality Measures (QM). I will report

e. Case Mix Index (CMI) only to look for major deviations from the mean.

The data that chains submit on themselves, and their facilities is almost hopelessly flawed in many cases, and CMS knows it. Multiple attempts to fix that problem have yielded little progress so far. CMS gets ethical data from the ethical. The inverse is also true. For my own assessments I attempt correct submitted data in a laborious research process and will do so in these regional reports.

There is nearly limitless other data available from CMS, some useful, but much of it notable for error and misrepresentation. CMS files much of the submitted data in its databases without requiring corrections, even for misspellings, numbers that don’t add up and omissions including data not provided or blanks. Analysts have to try to work around that.

Bottom line

All nursing home choices are very localized. Proximity is properly considered a virtue by loved ones.

This article provides a preamble to and explanation for upcoming reporting in this series on the options available to Virginians in specific regions of the state. The data reported are informed by this preamble. I will link back to it in each.

The reporting will prove surprising and alarming in many cases. And it should be alarming. Demand is not matched by supply. There are simply not nearly enough capably staffed beds to support the need.

Medicare Compare is by far the best source currently available to citizens to assess nursing homes when they need one.

The reporting in this series is a snapshot of a moment in time. Some of the data reported are available in Medicare Compare. The data I have learned to mistrust is available there as well. It is not reasonable to expect all of the information to be reported in this series to be accessed and assessed by individual citizens going forward.

But the current regional reports may prove informative, and often scary, nonetheless. And they may make readers very angry that the complex web of state and federal laws and regulations and their enforcement mechanisms has resulted in such a debacle.

Next.  Virginia Beach