Colonial Heights nursing home cited by VDH for deficiencies, then found compliant days before abuse complaint

By: Melissa Hipolit

COLONIAL HEIGHTS, Va. — Four days before Colonial Heights Police received a complaint about possible elder abuse and neglect at Colonial Heights Rehabilitation and Nursing Center, the Virginia Department of Health found the facility was in full compliance after finding several deficiencies during an inspection in early August.

The VDH inspector found staff at the facility failed to administer scheduled medications, lacked necessary supplies, and failed to provide incontenience care to a resident which caused them to get a severe rash on their buttocks.

The inspection report is dated Aug. 6, 2024 and details what an inspector found over several days in late July and early August after receiving nine complaints about the facility.

That’s just two months before Colonial Heights Police received a complaint of possible elder abuse and neglect from Adult Protective Services regarding a 74-year-old resident at the facility who prosecutors said died from Sepsis from wounds on her back and in her genital area.

Prosecutors said the woman was left in her bed for days in her own urine and feces, and her wounds from the poor care were so bad APS originally thought she might have been a victim of sexual assault.

The inspector reviewed the records of 23 out of 178 residents during the unannounced inspection.

They found one resident had a severe yeast rash on their buttocks.

The inspector said the staff failed to provide incontinence care to meet the needs of the resident and noted the facility’s nurses made no documentation of the rash prior to, or even after, a Nurse Practioner pointed it out to them.

The NP wrote in her notes “Patient has had this in the past…will be worse if she continues to lay in waste for hours. Instructed patient to advocate for herself by talking to the Director of Nursing regarding how long she is laying in waste.”

The inspector also noted staff:

• Failed to give a diabetes medication to one resident three Saturdays in a row
• Did not have self-catheterization supplies available to a resident so he was uncomfortable after not being able to empty his urine since the morning prior
• Failed to consult with a resident’s doctor and resident staff representative and failed to implement its abuse policy after the resident, who was classified as having severe cognitive impairment, was found engaging in sexual activity with another resident on two occasions. According to policy, any suspected or witnessed incidents of patient on patient abuse or exploitation brought to the attention of the administration will result in an internal investigation and reporting to the state survey agency. Failure by an employee to report any witnessed incident or mistreatment, abuse, neglect, theft or exploitation or reasonable suspected crime against a patient will result in corrective action.

The facility needed to correct the deficiencies found by the inspector by Sept. 18.
We asked VDH if they went back to check if the facility made the changes and a spokesperson said they conducted an “off-site” revisit on Oct. 1 to ensure compliance.

That was just four days prior to the APS complaint to police about the potential elder abuse and neglect at the facility.

The VDH spokeswoman said not all revisits are conducted on-site, and the severity of the citations determine if an on-site revisit is required.

We asked her what an “off-site revisit” entails and received the following information:

“An off-site revisit is a desk review of a health care provider’s plan of correction that includes examining credible evidence supplied by the provider. VDH carries out this review off-site.”

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Colonial Heights nursing home cited by VDH for deficiencies, then found compliant days before abuse complaint