HENRICO COUNTY, Va — A Henrico County nursing home is facing regulatory enforcement action after it was cited for serious safety violations by health inspectors. The findings sparked concern for the family member of a former resident who felt improvements at the facility have not taken place fast enough.
Marlene Cox said her mother had an unpleasant experience at Glenburnie Rehabilitation and Nursing Center back in 2021. While her mom was supposed to remain at the facility for a few weeks for rehab, Cox ended up removing her after five days.
“It was an absolute nightmare," Cox recalled. “I was able to get her transferred because it was so awful, and that five days seemed like forever.”
Among her complaints, which she documented in notes, she said her mother was not getting enough attention from staff, her call bell did not work the entire time, and she was left to sit in her urine for hours without getting cleaned.
“It was hard to fathom that she had been there most of the night, laying in her own urine, because they didn't even come in to check on her to see how she was doing," Cox said.
Virginia Department of Health (VDH) records have described similar incidents in the past.
During its most recent standard inspection in 2024, VDH found Glenburnie failed to provide regular incontinence care, with one resident reporting, "We have to call them to come when we are wet."
And earlier this month, CBS 6 received concerns that the call bells were not working at the facility for several days. Glenburnie spokesperson Mindie Barnett confirmed there was a "temporary disruption with the call bell hardware at the nurse’s station." She said replacement parts were ordered, and interim measures were put in place so residents could still get attention when needed. VDH said nonworking call bells would not necessarily constitute a deficiency as all facilities are required to implement alternative plans when equipment fails.
“It really hurts to know that this much time has gone past, and they're still operating the same way," Cox said.
Glenburnie is a for-profit nursing home operated by the chain Medical Facilities of America (MFA), which runs more than 30 other facilities across Virginia. MFA nursing homes were bought in 2021 by New Jersey-based company Innovative Healthcare Management.
Other facilities in the MFA portfolio include Westport Rehab and Nursing Center, Henrico Health and Rehab, and Colonial Heights Rehab and Nursing Center, which have all been on the receiving end of recent regulatory enforcement actions: Westport was fined and denied Medicare and Medicaid payments for new admissions due to violations, Henrico Health and Rehab was selected for a federal program reserved for the worst-performing facilities in the country, and prosecutors alleged abuse and neglect among other "complex crimes" at Colonial Heights which prompted a request for a special grand jury investigation.
Watch: Henrico nursing home identified as one of the worst care facilities in the country: 'It's like a madhouse'
Glenburnie has a 1-star quality rating and low staffing levels, according to Medicare, and has three times the number of violations on inspection reports compared to the average facility in Virginia.
Barnett said the facility "upholds the highest standards of care" and has a team that is "deeply committed to continuous improvement and transparent communication, always with the best interests of our residents at heart."
VDH made four complaint visits to Glenburnie between January and April of this year, and here's what inspectors found:
An intoxicated certified nursing assistant (CNA) allegedly verbally abused two residents by screaming and cursing at them, telling one resident, "If you take your brief off again, I'm going to [expletive] you up" and "God doesn't even want you here." The CNA was also heard stating that he overmedicated a resident to "put her down." The facility terminated that employee, and a police report was filed.
Glenburnie was also cited for failing to provide high quality care when staff were made aware of a possible overdose of a resident, who was only responsive to a sternal rub, and the nurse practitioner only gave telephone orders to "continue monitoring" the patient. That resident's family took it into their own hands to transport the resident to an emergency room and then never returned to the facility. The medical director told inspectors that he would have wanted vital signs and assessments to be obtained in that situation, and a licensed practical nurse reported the resident needed "urgent attention" and for 911 to be called.
Additionally, Glenburnie was cited for failing to maintain a clean and dignified room, failing to properly administer medications and treatments, and failing to ensure a patient was seen by a doctor within a required 60-day timeframe.
The most serious violation the nursing home faced was a failure to investigate and prevent fires that were set by a cognitively impaired resident. In January, the resident, who was already known to pose a safety risk due to his tendency to collect and use lighters, was believed to have lit a mattress in his room on fire and burned a curtain. At the time, the facility committed to implementing interventions like increased supervision and inspections of his room. However, VDH did not find evidence that those measures were actually happening, and in March, the resident started another fire using toilet paper in his bathroom. This resulted in a finding of immediate jeopardy, which is the most significant citation regulators use.
“It just astounds me that a business, that the facility, can still be functioning and somebody's not sounding some alarms, or the red flags aren't being raised to take care of that," Cox said.
The federal regulatory agency of nursing homes, the Centers for Medicare and Medicaid Services (CMS), sent a letter to Glenburnie saying it would deny Medicare and Medicaid payments for all new admissions beginning May 30. CMS warned the facility that a continued failure to comply with safety and care regulations could result in a termination of its provider agreement.
CMS oversight data also showed a fine had been imposed on the facility, but the amount is unclear.
“I think they should be held accountable. I think they should be cited," Cox said. "If somebody can't turn Glenburnie around, I think the doors need to be closed.”
In response to the latest inspection findings, Barnett said, “Our primary commitment is to the well-being and dignity of our residents. We are actively engaged with CMS and are maintaining open communication regarding the recent citations and necessary remedies. We are committed to full compliance. Our dedicated team is working tirelessly to enhance training and education, aiming to prevent any future issues and to ensure the highest standards of care are always met. To prioritize the safety and comfort of our current residents and provide the quality care they deserve, we have temporarily paused new admissions.”
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