COLONIAL HEIGHTS, Va. — Inspectors from the Virginia Department of Health, acting on behalf of the Centers for Medicare and Medicaid Services, substantiated ten complaints about Colonial Heights Rehabilitation and Nursing Center involving issues like wound care, inadequate staffing, including excessively low weekend staffing, the proper administration of medication, and lack of incontinence care during a recent inspection survey.
Their survey spanned 15 days and produced a 341-page report that was released to CBS 6 as part of a public records request.
VDH inspectors began their survey on the same day Colonial Heights Police arrested multiple employees at the facility in connection to a former resident’s death.
Cindy Wilson, a caregiver for veteran John Hill, previously told CBS 6 that she had serious concerns about the facility.
“He was crying, he was upset, he wanted to get out of there so bad, and I wanted the same for him because of the lack of care,” Wilson said.
Watch: Agency stopped sending veterans to these nursing homes amid 'care concerns'
Inspection findings
Inspectors found that for multiple reasons, staff failed to maintain the call light in a position where residents could access it to call for help.
For one resident, staff failed to ensure the resident, who had multiple fractures including the spine and pelvis, went to a follow-up doctor's appointment.
The resident stated they were told it was because the facility did not have transportation to get them to the appointment, which could not be rescheduled for another two-and-a-half months.
For another resident, staff failed to notify the physician of medications that were not administered on nine different occasions.
Inspectors also highlighted a resident who had a pressure ulcer on their sacrum and required interventions that included turning the resident often and keeping their skin clean and dry.
The inspector asked a certified nursing assistant (CNA) to turn the resident on their side after noticing the resident had been lying in the same position for three hours.
When the resident was turned over, a urine-soaked towel was wadded up under the resident.
“The smell of urine was very strong,” the inspector wrote.
When asked how often a resident is to be turned, the CNA stated every two hours, but this was her first day at the facility.
Inspectors interviewed several staff members at the nursing home who raised concerns about staffing at the facility.
One CNA said they were assigned to 15 residents on the day the inspector found a resident lying on a sheet with a “strong urine odor,” and it was impossible to get to each of them timely.
She said it would be easier to get to everyone in a more timely fashion if they had more CNA staff.
A licensed practical nurse (LPN) said she was trained in wound care and would normally be the treatment nurse, but she had not been doing treatments in a long time because she was always pulled to work on a medication cart due to staffing issues.
Another LPN stated she normally had 32 residents, and it was “overwhelming."
“A total disaster for any family member to be in,” Wilson said. “I’m praying that no one else ever again has to go back to that facility unless it’s better.”
To that point, several CNAs and LPNs said that once the state investigation began, staffing had dramatically improved.
An LPN said her “mind was blown” when she had four nurses on her unit, and it has made a difference in the care they provide.
Another LPN stated it was “so nice to be able to provide the care that the residents needed and not in a rush.”
A CNA stated that staffing started to drop in September and did not go back up until the state showed up.
She told the inspector that staffing improvements since the state arrived were "wonderful, they are getting the care that they need. We were not able to do all of the care before."
In the survey, Colonial Heights Rehabilitation and Nursing Center provided information about its plan of correction, and all the changes they planned to make, and the state noted that they complied with each of their deficiencies on February 16.
A publicist from a New York PR firm that represents the facility, Mindie Barnett, said “we have no comment” when asked about the survey’s findings.
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