HENRICO COUNTY, Va — A Henrico County nursing home has been identified as one of the worst long-term care facilities in the country, and is now subject to increased oversight by state and federal regulators due to a "history of serious quality issues."
Cynthia Jefferson and Sandy Patron see themselves as advocates for the seniors who live at Henrico Health and Rehabilitation Center in the county's East End.
"I start talking to some of these patients, and they start telling me these stories: how things were, how nasty their rooms were, how the food was," Jefferson said. "It's like a madhouse over there."
Their own loved ones have had experiences with the facility. Patron said her mother lived there for 100 days under Medicare insurance back in 2023.
"I went every day, she would be sitting in her poop," Patron recalled.
And Jefferson's aunt is a current resident.
"It just so happened I showed up and she was in the bathroom, and she rang the bell to come out, and the bell was just ringing. They never answer no bells. You can sit there hour, hour and a half, two hours, nobody comes," Jefferson said.
Their concerns are similar to some past findings in state health inspection reports.
In 2023, the Virginia Department of Health (VDH) cited the nursing home for long wait times to respond to call bells, with one resident telling investigators that she had to wait more than two hours for a staff member to answer the call bell while she was in pain. VDH also cited the facility for neglecting incontinence care which led to skin damage for one resident.
Additionally, the state found staff made "significant" medication errors and failed to intervene when a resident with a declining pressure ulcer experienced "significant weight loss."
"If you're not taking care of them to get them healthy, how are they safe? And when you're giving wrong medicine, you're not cleaning them, they're getting bed sores," Patron said.
Between 2023 and 2024, VDH said it cited Henrico Health and Rehab with three "immediate jeopardy" deficiencies, which is the highest severity level for a citation, and nine violations related to abuse and neglect.
According to the inspection reports, the nursing home failed to protect two residents from sexual abuse committed by a nurse aide in August 2023. For one of the residents, VDH noted that "the facility staff failed to take measures to protect the [resident] from their alleged perpetrator, which permitted the staff member to abuse the resident again."
Inspectors also faulted the facility for failing to properly investigate and report the incidents and found staff "grossly misrepresented" the allegations to state authorities.
Jefferson said she was the one who notified the alleged female victim's family member of the incident.
"I found the lady's daughter's name," Jefferson said. "I called her, and I told her what happened to her mother, and I said, 'You need to get over there to see what's going on.'"
The federal regulatory agency of nursing homes, the Centers of Medicare and Medicaid Services (CMS), has imposed at least four fines on the facility since 2023, totaling more than $200,000.
Medicare has now flagged the facility with two icons on its website. One icon indicates the facility has been flagged for abuse, and the other indicates a "history of serious quality issues."
The latter signals that VDH has placed Henrico Health and Rehab on a list of the nation's worst nursing homes called Special Focus Facilities. The list is reserved for underperforming facilities that "rarely address underlying systemic problems that give rise to repeated cycles of serious deficiencies, which pose risks to residents' health and safety."
Each state picks at least one nursing home to be actively enrolled in the federal program and a few additional facilities that also meet the eligibility criteria to be put on notice for potential enrollment.
As part of the program, Henrico Health and Rehab will experience more frequent inspections, escalating penalties, and potential termination from Medicare and Medicaid. The goal is to encourage the facility to improve its quality of care.
"If Medicaid stopped paying them, I bet they'll get their act together," Jefferson said.
"It should start from corporate, and then tinker down to the employees at the facility where they should be more concerned about how they're running their facility," Patron said.
According to licensing records, Henrico Health and Rehab is operated by Medical Facilities of America (MFA), a chain that runs more than 30 other nursing facilities across Virginia.
As CBS 6 first reported, VDH said MFA is run by "all the same people" as Innovative Healthcare Management, a company with a mailing address listed in New Jersey. VDH said Innovative acquired MFA in 2021.
At the time of that acquisition, the company also owned Colonial Heights Rehabilitation and Nursing Center, which is at the center of two active elder abuse prosecutions. According to the prosecutors' claims, a patient at the facility died in October 2024 from wounds she developed as a result of alleged inadequate care.
Innovative also owned Westport Rehabilitation and Nursing Center, where CMS denied Medicare and Medicaid payments for new admissions and Veterans Affairs paused patient placements due to "care concerns."
Out of 603 nursing home chains in the U.S. that are logged in CMS' nationwide database, Innovate was ranked #517 based on overall quality rating with 1.8 out of five stars. MFA was ranked #413 with a star rating of 2.2.
Jefferson and Patron said they believed increased oversight by health regulators and more scrutiny of Medicare and Medicaid payments could lead to improved care for residents.
"We just need to start being more vigilant," Jefferson said.
"We need to have more eyes on these facilities because that's our loved ones that they're supposed to take great care of," Patron said.
CBS 6 asked a spokesperson for Henrico Health and Rehab to respond to family members' concerns, the facility's past compliance history, and the nursing home chain's CMS ratings.
Mindie Barnett sent a statement that read in part, "We encourage our family members to reach out to the facility management with any suggestions for areas of improvement as resident satisfaction is a top priority. As always, we are committed to providing exceptional care for our residents, many of whom have complex needs. Our dedicated team works diligently each day to enhance care and improve the outcomes for those we serve."
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