I understand there is a lot of work still to do. A ton of work, in fact. But thank you for continuing to work towards a better way. In our rural area of Virginia, nursing homes are abysmal. We are slowly seeing some improvements but progress is incremental. They get dinged by licensure but very little changes. I'm talking about neglect. Insects. Rodents. Floors sticky with urine. Broken heat &/or air conditioning. Unchanged bandages, unaddressed fractures. You wouldn't put a stray dog in some of these places, but many times the choice is a lousy nursing home close by or a better one that you can't afford to visit. And unvisited people are prime candidates for the worst neglect. So, again, THANK YOU for tightening regs, decreasing backlogs, & increasing inspectors and please don't give up, just push harder & ask for more help. Those are people living in these places, and they don't deserve what they are getting.

Any tightening of oversight on nursing homes would be welcome.  My husband died in January after contracting flu at Lee Health & Rehab in Pennington Gap, where the staff masking requirements were not being enforced. 

Re: Nursing Home Administrative Sanctions Guidance Document

There have been plenty of news stories about inadequate or abusive nursing home care. I live in the Richmond area have been witness to multiple instances of poor care, inadequate staffing, and lack of education on the part of the people actually providing care in three nursing facilities. In spite of the fact I was visiting 3-4 times a week, and communicating regularly with nursing home staff, there were issues I was unaware of until outside hospice staff alerted me. I was helped to problem-solve some issues by the ombudsman for my region, but little changed, and ultimately without nursing homes knowing that trained observers are coming in, enforcement for infractions is inconsistent and can easily be hidden. Without regular oversight, we rely on nursing homes self-policing, and it is obvious that is not an effective strategy to protect vulnerable people, especially in light of the fact that most facilities are owned by for profit corporations. Nursing home work is undeniably physically and emotionally hard, but it is also work that requires trust, which regular inspection and oversight will help provide, along with actual consequences for repeated infractions. Our healthcare system is no doubt under great strain (or even broken) now. The patients in these facilities suffer a host of indignities and it is our responsibility to advocate for them, to say nothing of the money being paid for inadequate care. Good health care providers in these facilities are just as tired and burned out as the patients by the bad actors, and thus would benefit too from standard enforcement.

I was certified as a Medication Technician back in 2011 and began working at a new facility in Stafford County. What I witnessed during my short 8 months was tragic and ended a career before it had barely started. Staffing was the issue. CNA's that sleep during their shift, LPNs that leave controled substances on nightstands. Med Techs that sabotage med charts to deflect blame for improper dosing of patients. Memory care patients that fall out of bed multiple times on the same shift with the same staff members in charge. Stealing from patients, workers that come in late or not at all. All under the noses of so called directors whos only worry is filling the shift at the most cost effective method possible. Nursing homes and Assisted Living facilities need to hold their staff to higher standards and concequences must be severe when infractions are made. I lived it, I watched it happen and I left the field. If you have good qualified staff, you don't have issues. Hold your staff to a higher standard and your facility will run efficently.

https://www.vpm.org/news/2025-04-11/vdh-hhs-cdc-karen-shelton-219m-communicable-diseases-covid19/

• Severe Understaffing & Lack of Care: The facility is critically short-staffed. Residents who require physical assistance with eating and feeding are being left ignored, leading to a dangerous risk of malnutrition and dehydration.( Especially on weekends)
• Biohazard & Unsanitary Conditions: Residents are routinely left sitting in soiled diapers and soiled bedding for extended periods. 
• Pest Infestation: There is a visible infestation of cockroaches and other pests throughout the facility, creating an unsafe and unhygienic environment.
• Lack of Basic Hygiene: General cleanliness of the facility is completely neglected. Furthermore, personal grooming for the residents is not being maintained, stripping them of their basic dignity.

The conditions of Loudoun Rehabilitation and Nursing in Leesburg, VA are atrocious.  They are very poorly managed with administrators rarely lasting more than 6 months.  They have run off many of the caring staff members and are short-staffed.  They often do not order diagnostic tests and blood work timely, and it can take days to get results that are needed stat.  They must have incentives not to call 911 when residents need it because they rarely seem to call 911 until it's too late, and residents and families hesitate to call 911 because the facility shames them for doing so.  Residents are not changed for hours at a time, ones who want to get up are often left in bed all day, and residents are sometimes left alone in the dining room well after the others have been put to bed.  Many residents don't receive a balanced and varied diet, and the dietician is not doing her job.  Meal tickets often don't agree to what's served.  Many residents aren't offered sufficient hydration.  Management doesn't know how many Hoyer slings they have, but there aren't enough for the number of residents who require them.  Hoyer slings are often not cleaned and are used again once the urine dries.  Residents are put into urine-soaked beds.  Call buttons for some residents are often unplugged so that residents can't ring for emergency assistance and can't watch TV.  They have been running out of supplies, such as diapers (especially 3X size which means they put residents into diapers that are too small), gloves, masks, soap, etc. which has had a direct correlation to an increase in infections that have resulted in sepsis and death.  The Resident Council was taken over by management despite protests of residents and families. The facility can't effectively control the heating, air conditioning, and humidity levels.  If you join and read the Loudoun Aging Parents site on FaceBook, you'll see that our community is well aware of the neglect and abuse that goes on there, and some of the positive comments have been from staff and management at this or a related facility without any acknowledgement that it's a biased comment.  Yet, when OLC finally came out a couple of months ago after over a year of not showing up despite numerous and serious complaints being submitted, they only chose to investigate one death.  They gave this nursing home a "deficiency free survey," which the facility celebrated and bragged about on their Facebook site.  Did the inspectors actively seek out staff, visitors, etc. who witnessed the decline of the deceased?  Did they verify in the system if the medical records/notes had been updated after the fact to make it look like care was given when it wasn't?  Something seems very wrong as to why the inspector could come to this conclusion based on eye witness accounts.  Because retaliation is very real, why don't the inspectors change how they audit to pay more attention to anonymous complaints?  Why aren't the inspectors looking for patterns and trends related to the complaints, especially when suspicious deaths have occurred?  Why don't inspectors walk randomly into residents' rooms and take a detailed look for the conditions related to the above complaints?  As soon as an inspector shows up, additional staff is called in and the facility sweeps through the rooms to do their best to ensure they are in compliance so why don't inspectors stop this from happening?  There have been allegations of serious fraud so why aren't the financials being investigated?  Why aren't the staff protected when they take their mandated reporter duties seriously?  When residents are sent to the hospital, why aren't the hospitals taking their mandated reporter duties seriously, and if they are, then why does it take over a year for inspectors to show up only to look at 1 incident and find nothing?  In May 2025, OLC issued many pages of violations for this facility, yet they subsequently cleared all of them even though many of the same conditions were still occurring so the re-audit process failed.  Your entire inspection process needs to be revamped.  Why do the Ombudmen in Virginia have so little power to get nursing homes to change their bad behavior and no ability to assess fines since they are at the facilities much more often than OLC?  Unless there are serious financial consequences to the gross neglect and lack of care, changes will never occur.

The conditions and upper staff are very poor. The food is not eatable and doesn’t meet nutritional needs for the residents. The ratio of CNA to patients is poor. They spent money on renovations instead of the patient comfort. There is a mold problem in the basement that hasn’t been addressed and many patients have experienced respiratory issues. There are wonderful CNA staff but the agency people are terrible. The death of one patient this past summer was investigated but I feel it was swept under the rug and the staff went to lunch to celebrate the findings. The rooms bathroom are not cleaned on a regular basis. The common shower are dirty and equipment is stored in them. One has a broken handle for many months. One is so dirty. PT staff is good. I could go on and on. Terrible place. 

I am submitting this comment as the founder of the Connie Taliaferro Initiative for Long-Term Care Reform and as the daughter and advocate of a former Virginia nursing-facility resident.

I support the Virginia Department of Health’s effort to establish clearer and more consistent guidance for reviewing administrative sanctions against nursing facilities. The proposed guidance appropriately identifies serious and repeated noncompliance, actual or potential resident harm, abuse or neglect, failure to correct deficiencies, compliance history, and systemic operational failures as factors OLC should consider.

However, I am concerned that the guidance creates review triggers without establishing circumstances in which a sanction is required. The document repeatedly states that sanctions “may” be considered and explains that meeting a citation threshold does not necessarily mean a sanction will be imposed. Consequently, a facility could meet one or more serious sanctions-review triggers without receiving any sanction or the public receiving an explanation of why OLC declined to act.

Certain findings should require an appropriate minimum sanction. These should include:

• Actual resident harm;

• Substantiated abuse or neglect;

• Immediate jeopardy or another serious threat to resident health or safety;

• Severe compromise of residents’ quality of care or quality of life;

• Failure to correct a serious deficiency by the required correction date;

• Repeated failure to achieve or maintain compliance; and

• Systemic or persistent noncompliance that exposes residents to continuing risk.

The specific sanction may remain proportional to the severity, scope, duration, resident impact, and facility response. However, when one of these serious findings is substantiated, enforcement should not be completely discretionary. A review without a meaningful consequence does not provide sufficient accountability or deterrence.

The guidance should also state clearly that a serious first-time violation may result in immediate sanctions. OLC should not have to wait for a facility to receive repeated citations when a single violation causes actual harm, involves abuse or neglect, creates immediate jeopardy, or demonstrates that residents cannot be protected safely. Repetition may justify escalating a sanction, but it should not be required before the Commissioner acts to protect residents.

OLC should issue a written, publicly available sanctions-review determination whenever a sanctions trigger is met. That determination should identify:

• The trigger or triggers reviewed;

• The relevant findings and compliance history;

• The actual or potential effect on residents;

• Whether a sanction was imposed;

• The type and duration of any sanction;

• The reasons supporting the selected sanction; or

• If no sanction was imposed, the specific reasons OLC declined to act.

Public explanations should be required regardless of whether OLC ultimately imposes a sanction. Residents, families, advocates, prospective residents, and taxpayers deserve to know how serious regulatory findings were evaluated and why a particular enforcement decision was made.

The guidance should also establish a timeframe for completing sanctions reviews. Serious resident-safety findings require prompt decisions. An enforcement process that remains pending without a defined deadline may allow unsafe conditions or ineffective management practices to continue.

Citation counts can help identify patterns, but resident protection should remain the controlling consideration. One serious violation may justify immediate action, while repeated lower-level violations may demonstrate an escalating or systemic failure. OLC should examine the complete compliance history across inspections, complaint investigations, revisits, related regulatory areas, and prior corrective actions.

I respectfully request that VDH revise the proposed guidance to require sanctions for defined serious findings, expressly authorize immediate sanctions for serious first-time violations, establish sanctions-review deadlines, and require public written explanations for all sanctions-review decisions.

Michelle Taliaferro
Founder
Connie Taliaferro Initiative for Long-Term Care Reform
connietaliaferroinitiative@outlook.com