RICHMOND, Va — The quality of care in Virginia's nursing homes is getting worse, according to regulators, but so is the level of oversight from the agency responsible for holding facilities accountable to acceptable standards.
Those whose loved ones have been harmed at nursing homes call the combination of lacking oversight and declining conditions a "domino effect" that puts vulnerable residents at risk.
Failure, disbelief, and regrets
Tracey Pompey and Joanna Heiskill used to be strangers, but separate tragic nursing home experiences brought them together.
In 2015, Pompey's father was found dead at Glenburnie Rehabilitation and Nursing Center in Henrico County.
“He was face down on the floor in his room, and he was covered in stool," Pompey recalled.
An investigation by Virginia Department of Health (VDH) found facility staff knew that her dad was vomiting stool that day, yet failed to notify the family or a physician, resulting in a delay in treatment.
“It could have been different had they just sent him to the hospital," Pompey said. "I've allowed myself not to think about it, but it does bring up sad emotions."
Four years later, Heiskill's mother was rushed from what used to be Bonview Rehabilitation and Healthcare to a hospital with low oxygen levels. She later died.
Heiskill claimed the facility did not give her mom the proper medication. VDH inspection records showed her complaint was substantiated and further revealed that staff misappropriated her mother's money by applying to receive her social security benefits without authorization and withdrawing cash from her resident trust fund account.
“They failed my mother, miserably. They failed my mom," Heiksill said. “I regret putting my mother in the facility."
Letitia Edwards eventually became connected with Heiskill and Pompey and recently had a concerning experience of her own.
Her mother is currently in a facility that she does not want to name. In October of this year, Edwards said she discovered her mom in her bed with a broken leg, but she said staff could not explain how it happened and would not let her see an incident report.
“It just really pains me that it's not just my mother that has experienced this. I've witnessed at that facility a lot of neglectful things," Edwards said. "I'm in disbelief right now."
It's stories like these which prompted Pompey and Heiskill to form the group "Justice and Change for Victims of Nursing Facilities" to advocate for stronger laws and regulations to protect a vulnerable population.
But over the years, their disappointment has only grown, as they see the same issues that impacted their families continue.
Just this week, Colonial Heights Police announced multiple employees at Colonial Heights Rehabilitation and Nursing Center were arrested in connection to an alleged elder abuse case, after police said a patient was hospitalized due to alleged inadequate care.
The advocacy group believes cases like this could be prevented with more enforcement from regulatory agencies.
“Our government here in Virginia— we’re holding them accountable for what’s happening in these nursing facilities, and their silence is deafening," Heiskill said.
Watch advocate Joanna Heiskill calls on the government to show they care
Virginia's lacking oversight
It's the Virginia Department of Health that's responsible for ensuring nursing homes are meeting state and federal requirements. In order for facilities to be licensed at the state level and participate in Medicare and Medicaid programs at the federal level, the government sets health, safety, and care standards for nursing homes to meet.
But as CBS 6 uncovered in a previous investigation, when people submit complaints alleging poor care and conditions, VDH is often slow to take action.
For example, both Steve Lambert and Heather Tyler said they waited more than eight months for the agency to even open a case into their complaints, when federal timeline requirements say complaints assessed at even the lowest prioritization levels should be investigated within 45 days or during the facility's next inspection. For both Lambert and Tyler's complaints, an inspection had occurred after they submitted complaints.
“I found it very disheartening that the Department of Health had not responded," Lambert said.
“Get off your rear ends and do something about this. Make people responsible. Make them accountable for what their job is supposed to be," Tyler said.
A 2023 performance review of VDH by the Centers for Medicare and Medicaid Services (CMS), which monitors state agencies' oversight activities, found Virginia was failing to initiate investigations of the most severe complaints within a required 3-day timeframe.
CMS data also showed 71% of Virginia's nursing homes were overdue for inspection, as of December 2024. That's the third worst rate in the country and well above the national average of 20%.
It's unacceptable to U.S. Senators Tim Kaine and Mark Warner who allot CMS funding for oversight efforts.
“Why is Virginia so far out of whack from other states?” Sen. Kaine said. "If it was just a federal funding issue, yes, you would see Virginia with a poor track record, but it would match what other states’ track records are and I think this is obviously a significant issue for the state as well."
“I think it's an embarrassment that Virginia is so far behind other states," Sen. Warner said.
In a corrective action plan that VDH submitted to CMS in response to failures cited in the 2023 performance review, VDH said it "experienced a significant increase in the number of nursing home complaints." Data provided by the agency shows VDH received over 800 complaints so far in 2024, a 57% surge since 2018.
But VDH reported that vacancies of inspectors and supervisors limited their ability to respond within required timeframes.
It's coming at a time when the state is also "observing an overall decline in the care being provided to residents" and as CMS says it's "increasingly concerned" with the quality of care at facilities, especially those owned by private equity companies and investment firms.
“One of the things that I feel very strongly about is the way money dictates the care, the quality of care. I think our government can do better and should do better," Heiskill said. “Look at the massive amount of corporations that have recently been purchasing these nursing facilities, and they're being allowed to do it, again, with no oversight on what's going on.”
Then, there's the report from the state legislature's investigative unit JLARC which revealed a VDH plagued by years of financial mismanagement, operational challenges, and a staffing crisis. The latter of which rendered the agency "unable" to fulfill its regulatory obligations.
CBS 6 questioned Governor Glenn Youngkin about these escalating concerns.
“How did the oversight system get this bad, and what is your plan to fix it?” reporter Tyler Layne asked the governor during a public event.
“When we came in in 2022, the Virginia Department of Health was very— troubled, is how I'll describe it, and they were troubled in lots of ways. One of them was that they had not been able to really put together the organizational structure to provide the kinds of oversight necessary," Youngkin said.
But he said VDH has already been implementing recommended changes for improvement, and he expressed confidence that Health Commissioner Dr. Karen Shelton can right the ship.
After VDH initially declined multiple interview requests, Shelton eventually agreed to sit down and discuss these issues with CBS 6.
Health Commissioner acknowledges 'tremendous difficulty'
“What I've been able to gather through looking at federal data, looking at public records, is that when it comes to VDH’s regulatory responsibilities, it seems that the agency is significantly falling short of meeting those goals. Is that something that you as the Commissioner acknowledge?” reporter Tyler Layne asked Commissioner Shelton.
“I think that we all acknowledge that there's been a tremendous difficulty after COVID with a lot of healthcare workforce shortages, so both in the nursing home industry itself as well as within the Virginia Department of Health," Shelton said.
Shelton said she currently has a 46% vacancy rate of nursing home inspectors.
“How is that sustainable?” Layne asked.
“We are taking definite measures in order to increase that. We are looking at compensation studies for our current staff. Some of our vacancies— we have lost staff to other state agencies. Some of the state agencies pay more than we do for the same kind of investigations for other complaints," Shelton said.
Some of the other short-term administrative solutions Shelton has implemented include contracting temporary inspectors, focusing efforts on the most high-need inspections, and the agency has created a strike team to investigate complaints.
“Do you find that VDH is able to get around to these quick enough to your satisfaction?” Layne asked.
“We’re always striving to do better," Shelton responded.
Complaints assessed at the lowest priorities are the most backlogged right now, Shelton said. Federal rules require the agency to investigate nearly every complaint that comes in, and Shelton said only a small number of overall complaints received are outside of VDH's regulatory scope.
But the stakes are high when facilities remain unchecked.
A recent Congressional report title Uninspected and Neglected found "nursing home residents are the people who ultimately suffer when understaffing at state survey agencies reduce their capacity to oversee health facilities” and that “poor conditions... are directly connected to insufficient enforcement.”
“Do you believe that there is a correlation between lack of oversight and worsening conditions?” Layne asked.
"Well, I think it's really up to the nursing home industry themselves. It's the facilities who provide the care for the patients. So it's really incumbent upon them to be providing the best possible care for their patients," Shelton answered.
“It is, but it’s also the state's responsibility to hold them accountable if they're not doing that," Layne said.
“Absolutely," Shelton responded.
'Draconian' powers to hold facilities accountable
To that end, Shelton said Virginia is abnormally restricted in its enforcement options.
“Currently, the state powers are pretty draconian in nature," Shelton said.
By law, she said VDH has no authority to impose fines on poor performers without petitioning in court, put their license on probation, or require staff training. Shelton said these are typical enforcement measures that every other state in the region has access to.
On the federal level, CMS can impose intermediate sanctions, but Shelton said it's "very important" for the state to have those authorities too.
Watch Health Commissioner Dr. Karen Shelton discusses 'Draconian' state powers
Additionally, Shelton said state licensing fees for health facilities have not increased in 40 years, which is currently set at $1.50 per bed and capped at $500 per facility.
While VDH would typically collect $150 in licensing fees annually from a facility with 100 beds, Shelton said other states, on average, would collect around $5,000 for the same-sized facility.
An increase in fees would give the health department more money to hire inspectors, whose starting salaries currently range between $71,000-$82,000.
Shelton is calling on the General Assembly to change the laws in these areas, with support from Governor Youngkin.
The proposed measures to increase nursing home regulation come at a time when Youngkin has prioritized decreasing government regulations across his administration.
“Is this one of the areas, in your conversations with the governor, where he thinks there might be too much regulation?” Layne asked Shelton.
“I think by comparison, as I mentioned, you can look at the other states and other agencies and see that we do not have as much regulation as they do, and we're just trying to get up to speed to give us the appropriate tools to manage our job," Shelton said.
When pressed for a more direct answer to that question, Shelton declined to elaborate further, but noted that the governor supports VDH's proposed legislative priorities.
The issue of lacking regulation was also brought to a December state Board of Health meeting.
Vickie Runk, who runs assisted living communities in Lynchburg which are subject to different oversight standards than nursing homes, is the board member appointed by the governor to represent the nursing home industry.
She believes inspectors have been coming down hard on nursing facilities — but for the wrong things.
“While we're short, what we should be focusing on is care-related complaints, not the paperwork, the everyday compliance that is barriers to us focusing on the care," Runk said.
She said she supports VDH's legislative proposals, but right now, she wants investigators to limit the scope of their probes to the problems families care about most, not minor noncompliance issues.
“Those inspectors should be in there, integrated their focus on resident care, any possibilities of neglect or medication mismanagement, food that's not being properly distributed and prepared. If we're focused just on those charts and that paperwork and who signed off on something and who was trained by this person or who wasn't trained by this person, we're not focusing on care, and that's our job," Runk said.
Watch: Virginia Board of Health Member Vickie Runk Addresses Inspector Shortage
Though Virginia is seeking additional funding sources, Shelton said CMS has provided stagnant federal funding to states for oversight activities. Congress has not increased CMS funding in this area in more than ten years, despite requests under democratic and republican administrations for more money.
The commissioner acknowledged the frustration that some Virginians have expressed as they look to VDH for answers to their nursing home concerns.
She pledged that improving the oversight system was a top priority to her.
"Our nursing home residents are some of our most highly vulnerable population, and they deserve and they need great quality of care, high intensity care, and we are here to help to regulate the communities that do that, and to make sure that we're working together to facilitate that best care," Shelton said.
"And do you feel VDH is doing a good job with that right now?" Layne asked.
"We are moving forward at a fast pace," Shelton said.
'They've let us down'
While state leaders present an array of solutions, advocates remain doubtful.
“The lawmakers here, I just feel like they've let us down. They've let me down," Edwards said.
For years, they've written legislators, shared their stories, and lobbied for change — but they've seen little progress.
“It leaves me feeling very frustrated, very angry and just disappointed," Heiksill said.
“That's why our elderly in nursing facilities are suffering, and families are having to go through losing their loved one," Pompey said.
CBS 6 will monitor any proposed nursing home legislation in the upcoming General Assembly session and track its progress.
CBS 6 is committed to sharing community voices on this important topic. Share your Virginia nursing home experiences with the CBS 6 Newsroom.
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