HENRICO COUNTY, Va. -- Steve Lambert reflected on the better times, showing CBS 6 photos of his brother Winfred smiling and surrounded by family.
“We were having a gathering here, one of his more happier days," Lambert said. "He loved laughing."
That memory is a stark difference from the one Lambert has from December 16, 2023, when he visited his brother at Westport Rehabilitation and Nursing Center in Henrico County.
Winfred had just been admitted to the nursing home the day before in declining health.
“And immediately, we were horrified," Lambert said, showing CBS 6 pictures of the conditions in the room. “He was lying in a prone position. As you can see, the hospital gown is barely on him. He's on one shoulder. He's in a Depend.”
Winfred was found face down in his bed with his gown not covering him and his adult diaper exposed.
Lambert said his brother could not move himself due to muscle loss and could not speak up for himself due to an intellectual disability.
“I cried. My wife and I cried," Lambert said. "We sat him up on the bed, and he started crying.”
Lambert was also concerned about particles he found in the vents and large flakes of what appeared to be somebody else's skin.
"We looked around and there were large chunks of dead skin on the windowsill, on the floor, and all over his bed," Lambert said.
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PHOTOS: Westport Rehabilitation Nursing Center conditions
Lambert understands facilities like these must adhere to government standards and federal regulations on the care and safety of patients because he was an associate director with the Virginia Department of Social Services licensing division.
In that role, Lambert was responsible for overseeing adult services and enforcement and was involved in the process of inspecting facilities for alleged violations of state standards.
“And based on my professional experience, I found the condition that my brother was in, as well as the gentleman that was in the room with him, totally unacceptable," Lambert said.
So, the very next day on December 17, 2023, Lambert submitted a complaint to the Virginia Department of Health (VDH), the agency responsible for inspecting nursing homes as part of the Centers for Medicare and Medicaid Services (CMS) survey and certification program.
Lambert submitted another complaint on December 23, alleging Winfred, who had a compromised respiratory system, was placed in a unit for COVID-19 patients and then contracted the virus. CBS 6 contacted Westport multiple times requesting a response to the allegations in Lambert's complaints and has not yet heard back.
However, months went by without action from VDH.
“I found it very disheartening that the Department of Health had not responded," Lambert said.
On March 23, 2024, Lambert's brother died.
But he was still determined to have his complaints investigated.
“That condition could very well be more widespread. Now I can't say that it was, but unless you conduct an investigation, you don't know," Lambert said.
Lambert checked in with VDH in March to request an update and was told his complaint inspection was pending.
He checked in again in July, and still-- pending.
At that point, VDH's Director of the Office of Licensure and Certification Kim Beazley, told Lambert in an email that her office had received a "large number of nursing home complaints" and was grappling with a "number of vacancies."
CBS 6 confirmed through a public records request that the office is currently down 19 long-term care medical facility inspectors out of 48 positions – a 40% vacancy rate.
“My response would be, 'Well what are you doing about it?'" Lambert said.
VDH uses an intake prioritization system from CMS to determine how quickly it should investigate complaints.
The timeline separates allegations into immediate jeopardy, which requires a response within three days, and non-immediate jeopardy.
Depending on the severity level, allegations that fall into the non-immediate jeopardy category require inspection in 15 days, 45 days, or at the lowest severity level, potentially during the facility's next on-site survey.
VDH would not confirm how Lambert's complaints were prioritized and referred questions to CMS. A CMS spokesperson also did not confirm how Lambert's complaints were prioritized. CBS 6 submitted a public records request to the federal agency for the complaint prioritization, but a response is still pending.
Even if the alleged noncompliance was assessed at the lowest severity level, which meant no actual physical or mental harm may have occurred, CMS records showed VDH inspected Westport in February of this year, two months after Lambert's complaints were submitted. During the February inspection, investigators found the facility failed to implement a resident's comprehensive care plan which required repositioning the resident and incontinence care.
CBS 6 asked VDH whether Lambert's complaints should have been a focus area during the February survey, and a spokesperson did not answer the question.
The day after CBS 6 asked those questions, on August 14, Lambert said he received a call from a VDH inspector that she was on-site at Westport to investigate his complaints – eight months after Lambert submitted them.
Lambert was told he'd be notified of the results within six weeks.
“No one should have to live and be treated and cared for under those conditions, particularly if they can't advocate for themselves, which was the situation with my brother. [VDH has] a regulatory responsibility to provide the proper oversight of facilities like that," Lambert said.
But Virginia is falling behind almost every other state in the country when it comes to providing oversight.
Nationally, CMS data showed Virginia had the fourth highest percentage of nursing homes that were overdue for inspection at 66% of providers. The national average for overdue inspections was 22.7%, as of August 2024.
Virginia ranked 47 out of the 50 states for completing recertifications of nursing homes on time, which is required every 15 months. Only Alabama, Kentucky, and Maryland had higher percentages of uninspected providers.
The commonwealth was also significantly below the 2023 national averages for percentages of nursing homes that received a standard inspection and were investigated for complaints at 39% and 58% respectively. The national averages were 66.8% and 84% respectively.
“We’re dealing with some of the most vulnerable people," Lambert said. “And so they need a system in place to provide the proper oversight in a timely and effective manner to ensure that these vulnerable people are not harmed.”
CBS 6 requested an interview with Kim Beazley, but a VDH spokesperson declined.
According to Medicaid's website, Westport has a one-star health inspection rating with 62 complaints resulting in a citation over the past three years.
Nursing home inspection records for all licensed facilities are publicly available. You can find additional information by visiting the Nursing Home Care Compare website [medicare.gov].
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