HENRICO COUNTY, Va — The former administrator of Henrico Health and Rehabilitation Center is facing disciplinary action by the state after an investigation revealed findings of retaliation, failures to protect residents, and numerous care-related issues within the facility she managed.
As CBS 6 has previously reported, the East End nursing home has been identified by regulators as Virginia's lowest-rated facility due to a pattern of serious quality issues.
In a presentation to lawmakers last week, State Health Commissioner Dr. Karen Shelton said the Virginia Department of Health (VDH) has enrolled the facility into a federal program for the country's poorest performing nursing homes and has increased its level of scrutiny and oversight. That means more frequent inspections, also called surveys, and escalating penalties for infractions.
“If they still remain out of compliance, there are increasingly severe and progressive enforcement actions that can be taken. They cannot graduate from the program until they have achieved certain survey results, and if they do not meet the requirements, [the Centers for Medicare and Medicaid Services] will terminate their provider agreement," Shelton said.
Now, a recent case decision by the Board of Long-Term Care Administrators against former administrator Shondel Samuels is shedding more light on some of the nursing home's past troubles. In an order posted last week, the board moved to place Samuels' license on probation due to findings that occurred in 2022 and early 2023.
Here's why:
According to the case file, Samuels retaliated against a resident who complained to an ombudsman about conditions at the facility. After the complaint was filed, Samuels issued a 30-day discharge notice to the resident.
The board's report stated that for another resident, Samuels failed to protect her from abuse and neglect, citing an incident in which a nurse aide hit the resident in the face with an oxygen cord.
In another incident, the report said the incontinent resident needed her garment to be changed. However, staff said "she could sit in her urine until the next shift" because she had a bad attitude. The resident later developed wounds associated with moisture.
The report went on to state that Samuels failed to implement policies to prevent abuse. Specifically, it said Samuels allowed a nurse aide to continue working at the facility despite Samuels previously substantiating an allegation of abuse by the same employee. The employee was only finally removed after health inspectors found out and required the removal.
In a separate incident, a resident was found on the floor of her room with a bloody knot on her head. The resident reported that she had been beaten by a man and asked staff to call the police. According to the board, Samuels failed to investigate the allegations of abuse or ensure police were called.
And for another resident, the board said Samuels failed to protect her from staff members' verbal abuse and physical roughness. Additionally, Samuels did not ensure her call bell was answered in a timely manner.
The board's findings also listed several care-related failures including:
- A failure to ensure a resident's care plan was reviewed and revised after significant weight loss
- A failure to ensure a resident was not given unnecessary drugs which led to complaints of dizziness
- A failure to ensure the investigation of unexplained bruises on a resident
- A failure to ensure residents received incontinence care and bathing as needed
- A failure to ensure residents received prescribed medications
- A failure to provide an ongoing program of activities for residents
According to the case file, Samuels was terminated from Henrico Health and Rehabilitation Center, which is operated by Medical Facilities of America (MFA), in January 2023 after an inspection revealed the referenced deficiencies.
"Shondel Samuels has not been employed at Henrico Health and Rehabilitation Center (HHRC) for more than 2.5 years and was never employed by Medical Facilities of America. Since that time, she has had no association with either entity or any other facility of which MFA is aware," said Henrico Health and Rehab spokesperson Mindie Barnett. "We are proud of the team we have in place at HHRC who are fully committed to accountability and resident care.”
During a hearing before the board last month, the case file stated Samuels "accepted little responsibility" in her role as administrator. Instead, it said "she claimed that the deficiencies were either unfounded or caused by the acts or omissions of others or events outside of her control such as employee turnover."
The board moved to put Samuels' nursing home administrator license on probation for at least two years. A probation is a disciplinary action not as severe as a suspension or revocation. It allows for her license to remain valid but subject to certain terms and conditions.
During the probationary period, Samuels will be required to complete training, provide the board with inspection reports of facilities where she is an administrator, and self-report employment information. A violation of the board's order could result in further disciplinary action.
According to VDH and public records, Samuels was listed as the administrator of Blue Ridge Rehabilitation and Nursing in Harrisonburg for parts of 2023 and 2024. Current licensing records list Samuels as the administrator from January 2025 to present.
Blue Ridge Rehabilitation and Nursing has not yet responded to CBS 6's request for comment.
CBS 6 reached Samuels by phone to seek her side of the story, but the line disconnected after stating the reason for our call.
This is a developing story. Email the CBS 6 Newsroom if you have additional information to share.
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