Nursing Homes – What Could Go Wrong?

Mt. Vernon Healthcare Center Alexandria

by James C. Sherlock

I have written a lot recently about staffing shortages in Virginia nursing homes and the Commonwealth’s national ranking near the bottom of the states for staffing measures.

It is appropriate to ask why that matters.

Federal analyses of Centers for Medicare & Medicaid Services (CMS) data offer the answer.

In proposing to adopt the Total Nursing Hours per Resident Day Staffing (Total Nurse Staffing) measure for the FY 2026 program year and subsequent years, the rule-makers offered this:

Staffing is a crucial component of quality care for nursing home residents. Numerous studies have explored the relationship between nursing home staffing levels and quality of care. The findings and methods of these studies have varied, but most have found a strong, positive relationship between staffing and quality outcomes.

Specifically, studies have shown an association between nurse staffing levels and hospitalizations, pressure ulcers, weight loss, functional status, and survey deficiencies, among other quality and clinical outcomes.

The strongest relationships have been identified for registered nurse (RN) staffing; several studies have found that higher RN staffing is associated with better care quality. We recognize that the relationship between nurse staffing and quality of care is multi-faceted, with elements such as staff turnover playing a critical role.

Remember, the surveys are conducted both for CMS certification and Virginia licensing by the Office of Licensure and Certification (OLC) of the Virginia Department of Health.

I have always found that office to be staffed by exemplary public servants, even while there have never been enough of them.

But we’ll get specific about Virginia nursing homes and survey deficiencies as the answer to the question:

“What could go wrong?”

CMS maintains exhaustive data catalogues. The one used for this article is Nursing homes including rehab services data archive.

From the July 2023 file, I have culled Virginia nursing homes in data accessed this afternoon. As filtered and presented here, it shows only the most recent results of each of the 131 certified facilities in Virginia with one-star staffing assessments.

Those facilities were cited in their last inspection and near-term follow-ups (required because of poor biennial survey results) with 2,155 deficiencies, an average of 16.5 each. The average number nationwide is 10. The range of deficiencies in Virginia was from 1 to 72 (Mt. Vernon Healthcare Center in Alexandria).

Given that the inspectors review only a subset of a facility’s patients for the survey, that is a lot of deficiency citations. If you see in the spreadsheet, for example, two citations for the same deficiency, that means they found that deficiency for two different patients.

In gross numbers, the violations cited by inspectors of those 140 facilities included standards (alphabetically) for:

  • Administration Deficiencies – 62
  • Deficiencies of the nursing home environment – 50
  • Freedom from Abuse, Neglect, and Exploitation Deficiencies – 111
  • Infection Control Deficiencies – 158
  • Nursing and Services Deficiencies – 105
  • Nutrition and Dietary Deficiencies – 152
  • Pharmacy Service Deficiencies – 194
  • Quality of Life and Care Deficiencies – 498
  • Resident Assessment and Care Planning Deficiencies – 411
  • Resident Rights Deficiencies – 414

Mount Vernon Healthcare Center in Alexandria, cited for abuse and number one on the CMS list for designation as a Special Focus Facility (SFF), is, officially, the bottom of that barrel. SFF designation does not come with a trophy.

But the ownership proclaims “True Blue” standards of excellence. It’s on Vimeo, so it must be true.

Check out in the spreadsheet of CMS data Mt. Vernon’s survey deficiency tag numbers awarded since November of 2022; that facility failed to:

  • Tag 600, “Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody”;
  • Tag 602, “Protect each resident from the wrongful use of the resident’s belongings or money.”
  • Tag 607, “Develop and implement policies and procedures to prevent abuse, neglect, and theft.”
  • Tag 609, “Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.”
  • Tag 880, “Provide and implement an infection prevention and control program.”
  • Tag 726, “Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident’s well being.”
  • Tag 947, “Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.”
  • Tag 755, “Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.”
  • Tag 757, two counts, “Ensure each resident’s drug regimen must be free from unnecessary drugs.”
  • Tag 760, two counts, “Ensure that residents are free from significant medication errors.”
  • Tag 676, “Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.”
  • Tag 677, two counts, “Provide care and assistance to perform activities of daily living for any resident who is unable.”
  • Tag 686, “Provide appropriate pressure ulcer care and prevent new ulcers from developing.”
  • Tag 688, “Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason/”
  • Tag 691, “Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.”
  • Tag 741, “Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents/”
  • Tag 742, “Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder/”
  • Tag 825, two counts, “Provide or get specialized rehabilitative services as required for a resident.”
  • Tag 641 through 657, read all of the citations about faulty patient assessments and near-term care upon admission.
  • Tag 658, “Ensure services provided by the nursing facility meet professional standards of quality.”
  • Tag 571, two counts, “Limit the charges against residents’ personal funds for items or services for which payment is made under Medicare or Medicaid.”
  • Tag 568, “Properly hold, secure, and manage each resident’s personal money which is deposited with the nursing home”.

For the full 165-page report of the inspectors, see here.

Ask again: what could go wrong?

The good news: Mt. Vernon Healthcare Center is really close to Inova Mt. Vernon Hospital.

That nursing facility is owned by CommuniCare, a privately held company headquartered in Cincinnati, which is family-owned.

When you or your loved one come to Mount Vernon Healthcare Center, you can rest assured our skilled nursing team will help you achieve your highest level of wellness.

Good to know.

Its Virginia locations are Annandale Healthcare Center, Battlefield Park Healthcare Center in Petersburg, Cedars Healthcare Center in Charlottesville, the aforementioned Mount Vernon Healthcare Center in Alexandria and Petersburg Healthcare Center. Check them out at the Nursing Home Compare links provided.

All, including the Alexandria facility, are accepting new patients.

Somehow, none of that came up in hearings in the Virginia House and Senate this year on a new law that was passed to set nurse staffing minimums at 3.08 total nursing hours per patient per day on July 1, 2025. That standard is far below the 4.1 hours that the federal government has proven are necessary to assure the health and safety of the residents.

The members neglected to ask what could go wrong. Or to ask about the patients at all.

For reference, current total nursing hours per patient per day in 95 Virginia nursing homes are below that 2025 standard that the industry itself chose in the bill they wrote.

By current Virginia regulation, the Health Commissioner may

impose such administrative sanctions or take such actions as are appropriate for violation of any of the standards or statutes or for abuse or neglect of persons in care. Such sanctions include:

1. Restricting or prohibiting new admissions to any nursing facility;

She can use the 2025 Virginia minimum staffing standard.

That will yield temporary prohibition of new admissions in 95 facilities. If she were to use the federal standard of 4.1, she would extend the temporary prohibition to 226 of them. Virginia only has 290.

That action will fix the worst understaffing problems within three months as high-need skilled nursing patients leave.