CBS 6 investigation leads state to find 4 federal violations at Colonial Heights nursing home

COLONIAL HEIGHTS, Va. -- The Virginia Department of Health’s Office of Licensure and Certification investigated Colonial Heights Rehabilitation and Nursing Center after a CBS 6 investigation into an attack on a social worker by a resident and found four instances where the facility violated federal rules.

CBS 6 shared the voice of a former head of social work at the facility, Cassie Ortiz, last May.

She was assaulted by a patient at the facility, but no legal action could be taken because of the patient’s mental state at the time of the attack.

“I kept asking the patient to let me go, and he said, 'No, that I needed to perform oral sex on him.' And he just would not let me go. I was very scared,” Ortiz told us last year.

WATCH: She quit her job after a nursing home patient attack: 'It's a broken system'

The assault led Ortiz to forgo her dream of becoming a nursing home administrator for good.

“It's hard for me to leave something I absolutely love. I will never pursue it at this point,” Ortiz said.

Provided to WTVR

Colonial Heights Commonwealth’s Attorney Gray Collins said he could not pursue the case because of the patient’s mental state at the time of the attack, so a frustrated Ortiz shared her story with CBS 6 highlighting what she saw was a glaring safety issue.

While the facility provides short-term rehab and longterm care, Ortiz said when she was there, more than 20 psych patients lived on-site.

“Our job is not to manage psych patients, we are not equipped to do that,” Ortiz told us in 2023.

READ: Colonial Heights Rehabilitation and Nursing Center May 2023 Survey Report

As a direct result of our report, the Virginia Department of Health’s Office of Licensure and Certification went to the facility unannounced three days after our story aired and initiated an investigation on May 12, 2023.

While there they reviewed the files for 24 residents and found:

• The facility failed to investigate (1) and report (2) allegations of abuse involving one resident to the appropriate regulatory agencies on ten occasions, even after episodes of violence, inappropriate touching and offensive comments.
• Staff failed to request a reassessment of the pre-admission screening and resident review (3) for a resident with a known psych history.  This screening is a requirement to ensure that people with a mental illness are not inappropriately placed in nursing home for long-term care.
• The facility failed to ensure 12 employees had the appropriate competencies and education (4) to provide for the behavioral health needs of residents with mental health disorders.

WTVR

A month-and-a-half after their inspection, VDH followed up with the center to ensure they corrected the deficiencies and found all problems were corrected.

However, that follow-up was an off-site paper review, as opposed to an in-person visit.

READ: Colonial Heights Rehabilitation and Nursing Center June 2023 Survey Report

Colonial Heights Rehabilitation and Nursing Center received one star in a five-star rating system on Medicare.gov

We asked the facility what it is doing to ensure it can properly care for patients with psych issues, and how it is protecting staff and patients from safety issues involving residents with serious psychiatric problems.

Colonial Heights Rehabilitation and Nursing Center Administrator Shawanda Jeter sent me the following statement when asked about the VDH investigation:

“Colonial Heights Rehabilitation and Nursing Center strives to provide high quality care to all our residents. Our staff completed a plan of correction which was accepted by VDH/CMS for the deficiencies that were stated in the survey on 5/12/2023. We have remained in compliance under this plan since 6/20/2023. Our team of caregivers continues to receive training related to caring for residents with mental illness and those residents that display behaviors related to mental illnesses are evaluated by our physicians and psychiatric providers as needed. The recommendations made by these providers are followed to ensure optimal care is given to our resident population.”

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