RICHMOND, Va. — The number of severe violations found in Virginia nursing homes considerably spiked after state officials last year put a spotlight on long-term care accountability and oversight. These problems indicated residents were in serious danger.
At the same time, the state office responsible for ensuring resident protection continues to grapple with staffing challenges and a significant inspection backlog.
One year ago, former Governor Glenn Youngkin's administration made a promise to overhaul the nursing home oversight system, partly in response to CBS 6's reporting on growing care concerns and regulatory failures.
Watch: Governor, top health officials take action following CBS 6 investigations into nursing home oversight
At the time, the Virginia Department of Health's licensing office struggled with a nearly 50% staff vacancy rate, and 68% of nursing homes under its regulatory authority were overdue for routine inspection.
To turn that around, Youngkin issued an executive order in August 2025 with directives for VDH to hire inspectors and improve operational efficiencies.
So, what's changed since then?
Vacancies, inspection backlog decline but persist
Data CBS 6 obtained from VDH shows problems still persist with vacancies and late inspections, but in smaller numbers.
The data showed that as of July, 25% of positions in the division responsible for nursing home inspections were vacant. An additional seven authorized positions were not classified as either vacant or filled by VDH.
While the executive order and legislation that passed in the 2026 General Assembly session directed VDH to maintain an inspector recruitment dashboard, the agency did not provide a copy of it in response to a CBS 6 records request. VDH said the dashboard is "currently under redevelopment."
Data as of July also showed 58% of inspections were overdue, which licensing director April Dovel partly attributed to a surge in members of the public submitting complaints. The complaints, which typically allege issues such as neglect, medication management, and staffing, add to inspectors' workload.
Despite ongoing challenges, Dovel was optimistic about VDH's progress.
“It's still an uphill climb. I don't want to discount that there's a lot of work still left to be done, but really excited about the trajectory of where we're going," she said in an interview last month.
Watch: Nursing home oversight officials vow stronger enforcement as complaints surge, inspections lag
In July, VDH also unveiled new plans to get inspections back on track and strengthen enforcement.
Tracey Pompey, who leads the advocacy group Justice and Change for Victims of Nursing Facilities, believes these steps are overdue.
“A year later, they should not be still rolling out new plans. They should be actually activating those plans," Pompey said. “We don't feel that it's enough because number one, we need to have mandated staffing. We have to have mandated staffing. We have to have stronger penalties for facilities that continue to show a pattern of harm to the elderly.”
Immediate jeopardy violations spike
To Pompey's latter point, VDH's data does show an increase in the number of "immediate jeopardy" violations issued to facilities. These citations are the most severe, meaning the provider's failures caused or were likely to cause serious injury or death, and often trigger federal sanctions such as fines.
In an 11-month period before Youngkin's executive order, data showed VDH issued 30 such citations.
In the same time period after the executive order, VDH issued 53 such citations — a 77% increase.
“When families see consequences that are going to happen to these facilities, it is better, and it needs to happen," Pompey said. "You need to start hitting them in their pockets."
Here are some of the immediate jeopardy findings:
A February 2026 inspection, also called a survey, at Old Dominion Rehabilitation and Nursing in Newport News found the facility failed to protect two residents from being sexually abused across multiple documented incidents spanning several months.
Inspectors said one of those residents, who they said could not consent, "experienced repeat sexual victimization" by her power of attorney and two other residents. Inspectors said the facility was aware of incidents of sexual abuse, yet failed to put measures in place to protect others.
Federal data showed a fine of $305,340 in connection with this survey.
In response, Old Dominion Rehabilitation and Nursing said it believes the immediate jeopardy finding "was not justified because it did not fully reflect the circumstances or the interventions that the facility had already put in place."
"Specifically, the underlying incidents occurred several months before the survey and the facility had already taken significant corrective action in the interim. State surveyors subsequently verified implementation of those same corrective actions and the Immediate Jeopardy designation was ultimately removed," the facility said in a statement.
A March 2026 inspection at Petersburg Healthcare Center found the facility failed to protect multiple residents from abuse and neglect, which resulted in residents suffering a fracture, bloody nose, and scratches.
Inspectors said the incidents involved staff neglecting to appropriately use a mechanical lift transfer which caused an injury, two instances of residents assaulting other residents, and one instance of verbal abuse by a staff member.
Federal data showed a fine of $26,125 in connection with this survey.
Petersburg Healthcare Center has not returned CBS 6's requests for comment.
An April 2026 survey at Canterbury Health and Rehab in Henrico found the facility failed to protect multiple residents from abuse by a known aggressor. One resident was hospitalized as a result and reportedly died a short time later, according to the report.
Federal data showed a fine of $343,544 in connection with this survey.
Canterbury has officially disputed VDH's findings and said an outcome in its appeal is still pending. Administrator Veronica Haskins said in a previous statement that the resident in question "received well-managed care."
Henrico County
Henrico nursing home facing severe violations after multiple residents abused
When asked what's driving the increase in these severe violations, VDH cited multiple factors including changes in federal guidance on how to identify immediate jeopardy issues and the agency's expanded capacity to complete inspections and respond to complaints.
VDH said that's led to greater opportunities to identify more serious problems.
"What has not changed is our expectation that surveyors apply federal standards consistently and objectively. When conditions meet the federal definition of Immediate Jeopardy, surveyors are obligated to identify and cite them appropriately so that serious threats to resident health and safety can be addressed as quickly as possible," VDH spokesperson Logan Anderson said.
Some violations go unnoticed by inspectors
Federal monitoring of VDH's inspections shows state surveyors have missed some violations in nursing homes, meaning they did not identify all the problems that occurred in the facilities. The Centers for Medicare and Medicaid Services went behind the state on three inspections earlier this year, and in each, identified violations that the state did not catch.
In one inspection, CMS found VDH missed five of 17 violations — not counting additional violations CMS identified through its own observations. The missed citations included violations of quality of care standards, care plan review standards, and resident screening standards.
CMS noted none of the missed violations resulted in patient harm, but said the state did not respond to complaints on time, including one complaint triaged at the immediate jeopardy level.
A 2025 CMS performance review found VDH did not meet federal standards for reviewing monitoring reports like these — a quality assurance measure that's part of the agency's deficiency identification process. A corrective action plan called on VDH to document its discussions with CMS about those reports.
CBS 6 requested that documentation, but VDH said it did not exist. The agency said a corrective action plan was not required by CMS but it "does intend to review and discuss the results" of those reports.
Industry 'encouraged' by changes
The Virginia Health Care Association (VHCA), which represents nearly all nurings homes in the state said it is encouraged by VDH's new plan.
VHCA spokesperson Amy Hewett said it "addresses longstanding priorities for residents, families, providers, regulators, and other stakeholders, including timely oversight, survey consistency, workforce development, provider education, stakeholder engagement, and sustainable operations."
According to VDH's workplan, the VHCA, along with two other industry groups, were consulted to review and provide input on VDH's new enforcement and oversight framework. VDH's documentation did not list any consumer advocacy groups as being consulted for the plans.
VDH said the industry's perspective "was sought to provide operational feedback and should not be construed as the full stakeholder engagement process."
Pompey said she remains hopeful that new regulatory actions will improve the lives of vulnerable residents, though she's cautious.
More than a decade after her father's death in a nursing home in 2015, she said she's been disappointed too many times in what she perceives as state leaders' reluctances to installing meaningful reforms.
“There have been many times where I've said, 'you know, what's the point?' Because nobody's listening. Nobody’s listening," Pompey said. "So Virginia should be held accountable for the pain of family members that lose their loved ones.”
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