HENRICO COUNTY, Va. — The federal government has taken recent enforcement action against a Henrico County nursing home after an investigation found the facility caused harm to a resident who suffered a fracture due to a fall. That investigation came just weeks after a separate inspection resulted in findings that regulators said caused them to suspend Medicare and Medicaid payments to the facility.
The nursing home is Westport Rehabilitation and Nursing Center, a for-profit facility operated by Medical Facilities of America, according to Virginia Department of Health (VDH). The federal government gives the facility a 1-out-of-5 star rating for its staffing levels and inspection performance.
Complaints related to care, conditions
Beginning in December of 2023, Steve Lambert, whose brother had just been admitted to Westport, submitted complaints about the facility to VDH, the state agency that regulates and licenses nursing homes.
In his complaints, Lambert alleged concerns about the care his brother Winfred received and unclean conditions in his room. He showed pictures of what appeared to be dead skin cells covering Winfred's bed.
"It really bothered me. Based on hearing one of the staff saying, ‘We just don't have enough help to do everything that they ask of us.’ So given that that came directly from their staff, that really raised concern," he said.
CBS 6 first reported Lambert's story in August of last year, as it took the understaffed and overwhelmed health department eight months to begin investigating his complaints.
“They initiated the investigation the day after your story aired," Lambert said.
But since then, Lambert has received a series of letters from VDH with conflicting information as to whether his allegations were substantiated. After going back and forth with VDH several times, Lambert said his complaints were eventually re-investigated during a standard inspection that took place in November 2024.
According to that inspection report, Lambert's allegations were substantiated through deficiencies, but he said there are no documented findings that seem to pertain to Winfred's direct experience. He said he's still waiting for VDH to explain how his claims were apparently validated.
“It's not clear. Again, this just says, ‘noncompliance was identified, and deficiencies were addressed,' Lambert said while showing CBS 6's the letters from VDH. "I don't know which of the two [complaints], or even both were substantiated, so this letter is confusing.”
State inspections lead to enforcement actions
Here's what the 196-page report did find.
According to the November inspection report, which surveyed a sample of 69 residents and included investigations of 21 complaints, Westport:
- Failed to keep a clean, comfortable, homelike environment
- Failed to protect a resident from verbal abuse by another resident
- Failed to prevent the misappropriation of a resident's oxycodone, which reportedly went missing
- Failed to investigate the misappropriation of a resident's property after a family member reported missing clothing items
- Failed to implement plans to provide dependent residents with activities
- Failed to report allegations of abuse to VDH in a timely manner
Investigators reported that a resident said he was "left in his feces for five hours," was told to "shut up" by a nurse "because staff were working short," and that if "he wanted to stay alive, then he would need to be quiet."
Inspectors found that Westport violated quality of care standards by failing to provide appropriate care and services for catheter care, colostomy care, and parenteral fluids care, failed to give medications per the doctor's orders for several residents, and made too many medication errors.
Additionally, the investigation cited the facility for failing to keep respiratory equipment clean, failing to recommend an increase in depression medication for a resident with "death wishes," and recorded an inaccurate federally required assessment of resident's capabilities and health needs. That kind of assessment is typically used to determine Medicare reimbursements and to monitor care plans.
“Why is this facility still operating? I mean, I recall that there were over 100 pages of violations. I can't imagine a facility with that many violations," Lambert said after reviewing the inspection report. “It's scary to imagine what these people are going through."
Then just a couple weeks later in December 2024, VDH initiated another investigation of Westport for a complaint.
This time, inspectors faulted Westport for causing "actual harm" to a resident, which is a high-level violation. They said staff incorrectly used a Hoyer lift, causing a resident to fall out of it and fracture her pelvis. The investigation also cited the facility for failing to have competent nursing staff by allowing an untrained nursing assistant to operate the lift.
As a result of the findings, the federal regulator of nursing homes, which is the Centers for Medicare and Medicaid Services (CMS), imposed a $13,575 fine on the facility.
Additionally, CMS said certain deficiencies identified in the November inspection triggered a mandatory enforcement action to deny Medicare and Medicaid payments to Westport for all new admissions. The suspension was imposed on February 21, and as of last week, CMS said denial of payments was still in effect because Westport remained out of compliance.
Across the industry, Medicaid and Medicare are typically the primary providers of coverage for most nursing home residents.
"Facilities are given every opportunity to come back into compliance with all federal requirements to be certified as a Medicare and Medicaid provider. However, if a facility continues to remain out of compliance, CMS can issue a notice of involuntary termination which means that the CMS agreement has with the facility to pay for services furnished to Medicare and Medicaid beneficiaries would end," a CMS spokesperson said.
CBS 6 requested a response from Westport regarding the inspection reports and enforcement actions, and spokesperson Mindie Barnett said, “While an equipment failure led to a citation, the facility self-identified the issue and corrected the problem prior to the survey. All doctors, physician assistants, nurses, therapists, leadership and others within our community are committed to Resident health safety and welfare, as always.”
Lambert said he was happy to see action being taken, calling it "long overdue," but said he still wants to see the state oversight system improved across the commonwealth.
“If those who are charged with care and protection don't do their job, and many of these people don't have advocates who can be personally involved, then who's going to protect them? Who's going to protect them?” Lambert said.
This is a developing story. Email the CBS 6 Newsroom if you have additional information to share.
📲: CONNECT WITH US
Blue Sky| Facebook| Instagram| X| Threads| TikTok| YouTube
