COLONIAL HEIGHTS, Va — The federal agency that provides healthcare services to veterans stopped sending its patients to certain Central Virginia nursing homes, citing concerns about the care being provided and ongoing criminal investigations.
It was welcomed news to Cindy Wilson, a caregiver for nonverbal veteran John Hill who was a resident at one of the impacted nursing facilities.
"He was miserable. Each and every day he was in there, he was miserable," Wilson told CBS 6. "A total disaster for anyone to be in."
In July 2024, as Wilson was about to undergo knee surgery, she needed a temporary place for Hill to receive care.
She said Hill spent a few days at a Veterans Affairs (VA) hospital, and then the VA sent him to one of its contracted facilities: Colonial Heights Rehabilitation and Nursing Center.
But almost immediately, Wilson said she and her family were troubled by his experience there.
“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.
Among her concerns, she said Hill began to smell bad because he wasn't being bathed enough, his room was dirty, and he didn't receive requested equipment in his room such as a humidifier.
Wilson escalated her complaints to then-administrator Shawanda Jeter. In a letter sent to Jeter, Wilson cited Hill as having to wait "extended periods of time before receiving attention from staff," "medical needs not adequately addressed," and "instances of uncleanliness."
She also noted in her letter, "Your staff shared the shortage in staff."
“Were the nurses forthcoming in telling you guys, like, 'We don’t have enough people'?” reporter Tyler Layne asked.
“I had a couple of them that said so, 'We are shorthanded. We don’t have a lot of people,'" Wilson answered.
Wilson said Jeter did meet with her in person to discuss her concerns, but ultimately, she remained unsatisfied and removed Hill after about a month.
According to the Centers for Medicare and Medicaid Services (CMS), the federal regulator of nursing homes, Colonial Heights Rehabilitation and Nursing Center is a 1-star rated facility with staffing levels well below the minimum standard that CMS has deemed appropriate in order to provide safe care.
Issues at the nursing home have been well documented by regulators in recent years, with a 2021 inspection by the Virginia Department of Health (VDH) highlighting:
- A failure to notify a physician of resident falls
- A failure to develop a plan to address fall risks
- Rooms that were not clean
- The presence of cockroaches in rooms and units
- A failure to give residents showers
A nursing assistant told inspectors at the time that residents got one shower a month and "two if they get lucky." The employee stated their "workload is so heavy" and they were assigned "12-20 residents a day."
Then, in December of 2024, at least 18 employees, including Jeter, were arrested in an elder abuse investigation related to the alleged inadequate care of a patient who later died. Charges against staff range from falsifying records to neglect, and the cases are currently pending in court.
Watch: Nursing home workers arrested after woman's death. Judge calls case 'gut-wrenching' and 'horrendous' (Dec. 19, 2024)
Though the investigation is unrelated to Hill's care, Wilson wondered how much oversight the VA has of its contracted facilities and whether the agency monitors the level of care provided at those locations.
“He’s a veteran. Whether he's service-connected or not, he shouldn't be treated this way, and you all should find out or do more investigating of the places that you all send veterans to," Wilson said.
Amid the criminal investigation in December, the VA said it indefinitely stopped placing veterans at the Colonial Heights nursing home and successfully transferred patients to other facilities.
The VA said it also put a temporary hold on placements at Westport Rehabilitation and Nursing Center in Henrico County on Nov. 14 due to "care concerns." The agency did not elaborate further on those concerns but said future placements at that facility are under review.
As of Feb. 11, an agency spokesperson said both holds were still in effect.
Westport, too, is a 1-star, low-staffed facility, according to CMS data. It has also been at the center of previous CBS 6 investigations.
Watch: She submitted a complaint over 'deplorable' nursing home issues 8 months ago. The state hasn't investigated. (Sept. 25, 2024)
Heather Tyler, whose husband is a veteran and was referred to Westport by the VA, submitted a formal complaint to VDH in January of last year alleging poor care and conditions. Among her concerns, she said she found her husband with unexplained marks on his body and laying in his own urine.
“Absolutely pitiful, disgusting, deplorable, horrible. Any word you can think of that’s horrendous is the word for it," Tyler said about the conditions of the facility.
Tyler's complaint was substantiated by VDH in an inspection that CBS 6 reported on November 13. That same inspection report also revealed that staff failed to give HIV medication to a resident for three weeks, yet documented administering it anyway.
Local News
Report: Nursing home failed to give resident HIV medication for 3 weeks
Both Westport and Colonial Heights are under common ownership, according to licensing records. Virginia Care Holdco LLC is the holding company for the individual facility operators and landlords that lease the property to the operators. The landlords and operators are connected through common ownership, according to financial statements.
Innovative Healthcare Management, which has a mailing address located in Lakewood, New Jersey and voluntarily dissolved in 2024, is listed as the operational management company of Westport and Colonial Heights, according to CMS records. But the websites for both facilities recently announced "new ownership" and "new leadership."
According to VDH, the current operator is Medical Facilities of America, which operates dozens of facilities across Virginia. However, VDH said the operating staff of Medical Facilities of America is the same operating staff as the former operator, Innovative Healthcare Management.
"They are all the same people," a VDH spokesperson said.
For Wilson, she's thankful that Hill's nursing home experience is now behind him.
“Anybody that's running these facilities and not checking to see how well that the patients are being treated or taken care of, they need to be held accountable," Wilson said. “I’m glad that he's out of there, and I'm glad that they're under investigation. I'm praying that no one else ever again has to go back to that facility unless it’s better."
CBS 6 requested a response to the actions by the VA, complaints about Hill's care, and the ownership structure of the nursing homes.
Mindie Barnett, the publicist for Colonial Heights Rehabilitation and Nursing Center, did not directly address each question, but in a statement, she said, "We have no comment, due to the ongoing investigation, except to say that there are material inaccuracies which you have reported to us."
She did not provide further comment when asked to explain specific inaccuracies.
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