Why Was Canterbury Short of Staff?

by James C. Sherlock

The image above captures financial information about Canterbury Rehabilitation (known as Lexington Court until new ownership this year) published on the Virginia Health Information website for the fiscal year ending Oct. 31, 2018. That is the most recent data available to the public.

Canterbury, to refresh your memory is the privately owned Henrico County nursing home for Medicaid patients where the COVID-19 virus has killed 46 patients so far — the deadliest outbreak in any facility in the country. It is a national scandal that cries out for explanation. One angle worth exploring is whether the nursing home could have afforded to hire additional nurses, and whether better staffing could have prevented or slowed the spread of the disease.

I can’t answer the latter question, but the VHI data allows us to address the former. If we compute the nursing home’s operating margin by dividing operating income of $876,728 by operating revenue of $15,132,121, we get an operating margin of 5.8%. That is a healthy margin for a Medicaid nursing home.

Now, if we review staffing levels, updated on March 31, 2020, as found on VHI, we see that Canterbury/Lexington Court needed two additional RNs to reach the national average RN hours per resident per day of 41 minutes.

Had Canterbury hired another Level One RN (right out of nursing school), it would have incurred additional cost of roughly $103,000 — $63,400, the median nursing salary in Virginia, plus $40,000 more to cover administrative and benefit costs. That done, Canterbury (Lexington Court) would have made $773,728 that year, producing an operating margin of 5.1%, still very healthy. Had the nursing home hired two Level One RN’s, the operating margin still would have been a respectable 4.4%. Perhaps management tried to hire and no candidate applied. We don’t know. It’s worth finding out.

So, why did Canterbury/Lexington Court not hire more nurses? Did the state order the nursing home to do it and it the nursing home fail to comply? The state has the relevant inspection reports and, if it is doing its job, letters of correction. The Commonwealth should release that information to the press. If not, a FOIA request can sort it out.

[1] salaryhttps://www.salary.com/research/salary/alternate/registered-nurse-rn-level-1-salary/va

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25 responses to “Why Was Canterbury Short of Staff?

  1. Jim – how is the average number of residents per day “standard” calculated? When the chart says Canterbury had 166.2 average versus a 85.9 national average, what does that mean in practical affect beyond staff, if anything, like size, rooms, whatever?

  2. re: ” So, why did Canterbury/Lexington Court not hire more nurses? Did the state order the nursing home to do it and it the nursing home fail to comply? ”

    Interesting issue. I always thought one of the benefits of the private sector was that they were much better at finding efficiencies that the govt was especially when govt bean-counters would try to determine proper staffing levels for something.

    One would think, (perhaps wrongly), that the role of the govt in nursing homes would be to keep metrics on performance and outcomes and let the private sector folks figure out the most cost-effective way to achieve those results.

    Seems like when/if the govt gets involved in specifying actual staffing levels, it somewhat defeats the purpose of letting the free-market work it’s magic.


    • Once upon a time I had a lawn service that came to my house every spring. I paid them to take care of my lawn. They fertilized and sprayed for weeds. They put down mulch. But I noticed that the weeds came back by July and the fertilizer killed parts of the lawn. Plus, the mulch was discolored and smelled funny.

      So, I fired them and hired a new, different company. Now things are fine.

      I guess if I were Virginia’s state government I would have first rated the company as “one star”. Then I would have filled out a negative questionnaire. Then I would have paid them. Next year when the screwed up the lawn again I would have given them another bad review, written them another nasty letter and paid them again. The year after … well you get the point. Eventually their inferior service and poisonous fertilizer caused a bunch of kids playing on my lawn to get deathly ill. At that point I would shrug my shoulders and say, “But I rated them poorly and wrote them angry letters. It’s not my fault”

      Our state government paid Canterbury with money that was property of “We the People”. If the conditions were routinely unacceptable why did the custodians of our money keep paying an inept vendor?

      The free enterprise system works because customers have choice and use that choice to abandon poor performers who then go out of business. When the supposed custodians of our money no longer exert a fiduciary responsibility with regard to that money there is no longer free enterprise. I don’t know what the resulting economic model should be called – Clownocracy? Whogivesadamnism? Or just … Virginia state government as usual.

      • Isn’t it ususally CMS that shuts down the funding?

        sorta like this:

        “CMS officials on Wednesday said they will publish a previously undisclosed list of more than 400 nursing homes that have been cited for persistent health and safety violations but haven’t received increased federal scrutiny.

        The agency has been criticized for its lack of transparency and failure to report some underperforming nursing homes. The list includes “candidates” for the CMS’ Special Focus Facility initiative, which gives operators with persistently poor care records incentives to improve their performance. The nursing homes undergo increased site inspections and incur penalties up to being excluded from Medicare and Medicaid.

        CMS Chief Medical Officer Dr. Kate Goodrich did not provide a time frame for when the agency would post the list.

        “Oversight of America’s poorest quality nursing homes falls short of what taxpayers should expect,” the report said.

        But the Nursing Home Compare site doesn’t mention whether nursing homes are candidates for Special Focus. The Senate report found the star ratings of candidate nursing homes did not always reflect their status. More than a quarter of candidate facilities had a two-star rating and 48% achieved three stars or higher for quality. Nine Special Focus candidates scored a five-star rating for staffing and quality, according to the report.

        The CMS usually chooses approximately five of the poorest-performing nursing homes to participate in Special Focus, and states pick the best candidates. The selected nursing homes usually have similar quality and safety performance compared with other candidates.

        Special Focus nursing homes receive an inspection every six months compared with at least once every 15 months for all other facilities, including Special Focus candidates.

        Approximately 3% of nursing homes participate or are candidates for Special Focus. Goodrich said more than 90% of participants end up “graduating” from the program by sustaining significant improvements for about 12 months. About 10% of program participants end up being banned from receiving Medicare and Medicaid, which often times leads to a nursing home shutting its doors soon after.”

        This sounds like CMS is running the show, no?

    • No. Health and safety monitoring in healthcare facilities it licenses is a primary government responsibility. 100% of the population would agree with that. Nobody to pick a fight with.

  3. re: ” Health and safety monitoring in healthcare facilities it licenses is a primary government responsibility. ”

    But don’t they do this by looking primarily at metrics?

    Similar to hospitals where they look at metrics but don’t tell the hospitals how to staff?

    • No a third time. The monitoring for both state inspections (every two years) and CMS Medicare/Medicaid inspections (every year unannounced) is done by state inspectors. The CMS inspections are done by the state under contract to CMS. The rules for those inspections are provided by the CMS State Operations manual and the Code of Federal Regulations. The authority and responsibility for punishment of violators lies with the state. It is an unusual arrangement, but one the states lobbied for.

      • Is CFR the Code of Federal Regulations?

        The point is that it is CMS and the Federal Code that mandates the state’s responsibilities as well as sanctions to the state for failure to accomplish their responsibilities.


        CMS is the top level authority here and the CFR are their regulations not state regulations.

  4. No again.
    42 CFR 488.301
    “A State must establish, in addition to termination of the provider agreement, the following remedies or an approved alternative to the following remedies for imposition against a non-State operated Nursing Facility (like Canterbury):
    (1) Temporary management.
    (2) Denial of payment for new admissions.
    (3) Civil money penalties.
    (4) Transfer of residents.
    (5) Closure of the facility and transfer of residents.
    (6) State monitoring.

  5. Re: “One would think, (perhaps wrongly), that the role of the govt in nursing homes would be to keep metrics on performance and outcomes and let the private sector folks figure out the most cost-effective way to achieve those results.” I know you’re trying to drive a message home here about inconsistent conservative views, but let me take your statement at face value. Transparency is good in itself; I hope we all agree on that. The VDH data does shed some light on the situation; that’s good (except for the totally unnecessary 1-year delay in releasing 2019 data).

    But, based on that data, what enforcement is the private sector with its ‘market forces’ supposed to bring to bear? Are consumers so aware of these ratings that, realistically, consumers are going to make the decision often enough to avoid these cattle-barns for their loved-ones that the homes will have to amend their ways? Are there nursing home trade groups that self-police, calling out sub-par members, in order to sustain the industry’s overall reputation for quality? No; of course not! This is a classic legal situation where the State has to intervene in order to protect public health and safety because no-one else will, and because the public demands that somebody do it. The State should not only be transparent in identifying these behaviors but also should enforce standards where necessary. Enforcement means you have to have standards to begin with, and you have to police those standards, and you have to make the consequences of violating those standards so painful that the violations cease.

    That, however, does not mean that the free market has no role here. It simply means the free market has only what’s left. Nursing homes are free to exceed the minimum standards and brag about it in order to attract clients that way; but the minimums ought to be State enforced. [We all know the State can get carried away with micro-managing through “minimum” standards but that’s another discussion.]

    So when you say things like, “Seems like when/if the govt gets involved in specifying actual staffing levels, it somewhat defeats the purpose of letting the free-market work it’s magic.” — you are totally ignoring the difference between minimum standards and simply running the entire place as a government enterprise, like an elementary school. We know what kind of problems that entails!

  6. DJR makes a valid point that the State as the customer placing senior citizens and others receiving State aid in these sub-par nursing homes, has a special fiduciary obligation to its wards to ensure that they are placed in caring, well-staffed facilities. Even if the State’s reports are beyond the ability of the average consumer to interpret, let alone even see, the State itself has that knowledge and ought to act on it.

    But I will hold out for enforceable minimum standards, here. There are times for the State to act to uphold health and safety standards and this is one of those times. The average consumer shopping among nursing homes is not the user but a relative. The relative, even if well intended, may be desperate for a quick solution and is rarely knowledgeable enough to check it all out; and all too often will settle for the lower price if the facility looks halfway decent, or maybe not even that good. The State needs to protect the elderly, directly; they are citizens too.

    • re: ” DJR makes a valid point that the State as the customer placing senior citizens and others receiving State aid in these sub-par nursing homes, ”

      important to distinguish between who is paying and the nursing home itself.

      For instance, not everyone in a given nursing home is paid for by Medicaid. Some people are paying out of their own assets. Some may have long term care insurance. So the State is just one “payer” of many.

      The second part is the State and CMS being regulators so in that regard the State is wearing a different “hat” , that of the regulator, not the customer.

      CMS, on the other hand is wearing both hats. They CAN, as DJ says, pull the Medicaid funding from that facility and they have done it for many nursing homes and once they pull that funding, it might well depend on how many of the patients are actually paid for by Medicaid.

      To point out – that there are some top-rated nursing homes in the US and Virginia but they cost far more than the Medicaid reimbursement so their funds come primarily from non-govt sources, from people who have sufficient means to pay for more/better care than the kind that Medicaid will buy.

      Facilities that have a high percentage of Medicaid clients are not able to afford a higher level of care that one might find in nursing homes that charge more and the people in those facilities can afford it.

      Anyone here who has directly looked for a nursing home for a relative or knows someone who has – knows – that the costs of a nursing home often will require most of the income and assets of average retired folks who had average paying jobs. Medicaid also has a “claw-back” for assets that were transferred before the recipient went into a nursing home claiming poverty.

      Like with health care – the folks who have more income and assets will get more/better and when it comes to nursing homes, those with minimal assets do not get excellent care.. they get what the facility can afford to give them when Medicaid is not really paying enough for more/better staffing and other.

      This is an important issue for more of us to understand the realities of and really ought not be about “government failure” when the real failure is people who do not save enough for their care and then end up expecting taxpayers to pay the bill while they try to give their remaining assets to their kids. That’s way more than “government”.

  7. Yep agree and two points:

    1. – CMS can withhold Medicare and Medicaid funding anytime they feel it
    is warranted – and they DO

    2. – CMS also decides if VDH is performing their role acceptably and CMS can and does issue sanctions to State health departments that fail in their responsibilities that are outlined in the CFR –

    It could be in the case of Cantebury that the Medicaid funding is pulled AND the state is found remiss in their responsibilities.

    When and if CMS does that – will surely have implications for VDH leadership.

    I only point out once more that VDH is responsible for 280 nursing homes in Virgina and if they are remiss in their mission, it would likely affect more than a single nursing home unless someone can show that they specificially failed in their mission on only this nursing home – which is not impossible – sometimes people are “friends” and do not want to bring harm to their personal friends.

    VDH is, in fact, located near the facility and it is possible that VDH leadership personally knew the folks who ran the facility – personally. That’s pure speculation on my part. I’m only allowing that there certainly might be a good reason why only this nursing home appears to have been cut more slack than others. But also, no question that CMS was fully aware. It was CMS who gave the facility one star.

  8. I think a CMS audit of VDH records on its inspections of nursing homes and the follow-up to those inspections is warranted because of the issues in the public record concerning Canterbury, which represents the largest COVID-19 related loss of life in any nursing home in America. The rules are set out very clearly, though the inspectors certainly have some professional judgment leeway in assessing the severity and potential implications of any single violation. Such an audit is the only way Virginian’s and CMS will know if such things not only have been done properly in the past but importantly will be done properly in the future. I will write CMS Administrator Seema Verma requesting such an audit. The Governor should do the same.

    • And I agree and again point out, that such an audit should include all 280 other nursing homes to see if VDH had an organizational failure or if Cantabury was an outlier.

      The COVID 19 issues with nursing homes is nationwide and while Virginia has the worst, there are many others not far behind… Most nursing homes are simply not set up to deal with a virus as contagious as this one. It’s an industry-wide issue.

      Either way, facts and evidence should be the approach, not individuals who have a bone to pick with VDH or Northam.

      Let the process work and if VDH leadership failed their mission then make changes.

  9. A very interesting and informative discussion. I need more context to better understand the points that have been raised here, some of which might be contained in Jim’s earlier post(s) on subject. I’ll do that here tomorrow. Thank you Jim S, Larry, Don, and Acbar.

  10. Interesting article:

    Hundreds of nursing homes in areas with outbreaks have repeatedly violated infection control rules
    Of about 650 homes with publicly reported coronavirus cases, 40 percent have been cited more than once with violations related to infection control, a Post analysis found

    Forty percent of more than 650 nursing homes nationwide with publicly reported cases of the coronavirus have been cited more than once by inspectors in recent years for violating federal standards meant to control the spread of infections, according to a Washington Post analysis.

    Since 2016, the nursing homes accrued hundreds of deficiencies for unsafe conditions that can trigger the spread of flu, pneumonia, urinary tract infections and skin diseases. Dozens were flagged by inspectors only months before the coronavirus pandemic struck the United States.

    Among the facilities with infection-control infractions: the Pleasant View Nursing Home in Mount Airy, Md., where 24 people had died as of Thursday; the Canterbury Rehabilitation & Healthcare Center near Richmond, with 49 deaths as of Thursday; and the Brighton Rehabilitation and Wellness Center in southwestern Pennsylvania, where officials have warned that all 750 residents and staff members could be infected.


  11. Why the quick after hours knee jerk reaction, Larry?

    Are you back to typical blog behavior?

  12. James C. Sherlock,
    Really want to thank you for these articles as well as your patience and diligence in adding the additional details in your comments. You have provided details and a perspective not available anywhere else for all of us who have aging parents issues or will soon be in one of these places ourselves. This is a BLOG at its best.

    • SGillispie says “You have provided details and a perspective not available anywhere else for all of us who have aging parents issues or will soon be in one of these places ourselves. This is a BLOG at its best.”

      I agree. Also, if the State of Virginia, as now suddenly claimed, sees the problems Jim S. has raised on this blog, in a new light and with a new urgency after years of apparent inaction, then Jim Sherlock’s efforts to date surely deserve significant credit for that abrupt turnabout and action by the state.

  13. I too would like to thank Jim for his usual very thorough effort to provide an ample amount of information to include his practice of footnoting his references.

    And on the regulation issue with respect to CMS and VDH – I ran across this in my search find out if other nursing homes are also affected by the issues that are affecting Cantabury.

    And the plot thickens with respect to any thoughts that CMS will take
    action against Cantabury or VDH with regard to infection control.

    ” The Trump administration last year moved to roll back regulations aimed at preventing infections from spreading in nursing homes, a decision that is facing renewed criticism for endangering the elderly amid the coronavirus outbreak.

    With older, vulnerable residents living in close quarters, nursing homes face a heightened risk from the coronavirus — a majority of the nine deaths reported in the U.S. so far from the virus were residents of a long-term care center in Washington state. But over the last three years, the Trump administration has advanced — with the support of the nursing home industry — an effort to ease regulations on long-term care facilities and has taken significant steps to reduce fines for violations.

    Of particular concern in nursing homes is what experts call “infection control” to halt or prevent the spread of disease within health care facilities. Last July, the Trump administration proposed rolling back regulations requiring all nursing homes and other long-term care facilities to employ infection prevention specialists at least part time, citing “excessively burdensome requirements” on the industry. Under the proposal, which is still working its way through federal rule-making, nursing homes would be allowed to use consultants for infection prevention rather than hiring staff.

    “These are frail, medically compromised people, and they need to have someone focused on infection,” said Toby Edelman, a senior policy attorney at the nonprofit Center for Medicare Advocacy who opposes the proposed change.”


  14. and this – which I hope Jim will report on in further detail. It looks like the State is taking real action to address the nursing home issues:

    “Northam’s new task force promises action to help long-term care facilities in Virginia battle the coronavirus

    A newly appointed gubernatorial panel is promising aggressive action to help nursing homes and other long-term care facilities facing a lethal threat from the spread of COVID-19 through their medically vulnerable populations.

    The task force, led by Virginia Deputy Health Commissioner Laurie Forlano, began its work on Thursday with an urgent agenda that includes plans to expand the availability and guidance for testing to track the disease, procure and distribute protective medical gear to facilities that need it, and find money to help all facilities hire and keep critical staff.

    The plan includes a wide range of state agencies to carry out the mission — from the health and social services departments to the Virginia National Guard — not unlike the “strike force” concept that Maryland Gov. Larry Hogan unveiled more than a week earlier.

    The goal of Gov. Ralph Northam’s task force is to “understand the need very quickly and deploy the resources very efficiently, so I think we’ve achieving the same thing,” Forlano said in a 30-minute interview Thursday in which Deputy Secretary of Health and Human Resources Gena Boyle Berger also participated.

    One of the top targets is testing, which hampered efforts to control the spread of COVID-19 in Canterbury Rehabilitation & Healthcare Center and other long-term care facilities across the nation.

    The skilled nursing facility in western Henrico County has suffered one of the deadliest outbreaks of COVID-19 in the country with 49 deaths. Three more residents died on Thursday, two at the center and one in a local hospital.

    A push to test all residents of Canterbury last month was delayed because of public health guidance to reserve the limited number of test kits for those residents showing symptoms of the virus. After the release of a study of residents in a nursing home in Kirkland, Wash., that showed a majority with the virus didn’t show symptoms, the Henrico Health District tested every Canterbury resident on March 30.

    The tests revealed that more than half of the 92 residents who tested positive then — not including 16 who already had died — had not shown symptoms of the disease. A total of 128 residents, including those who died, tested positive during the outbreak, which began March 18.

    “That guidance has evolved,” said Forlano, former state epidemiologist and now deputy commissioner for population health at the Virginia Department of Health.

    “The Health Department supports the concept of patient prevalence testing, regardless of symptoms,” she said, referring to testing of all people in an affected cluster. “That was not always the guidance.”

    The department’s Henrico Health District is preparing to help test all residents of the Health Care Center at Beth Sholom, a retirement community that confirmed late Tuesday that 25 residents and staff members had tested positive for COVID-19 in the skilled nursing unit, or more than three times the number at the end of last week.

    Morris Funk, president and CEO of Beth Sholom, told residents and families on Thursday that only residents of the health care center would be tested because the virus had emerged only there.

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