CHESTERFIELD, VA — Eighteen staff members at Colonial Heights Rehabilitation and Nursing Center are facing felony charges following the death of a 74-year-old resident with cerebral palsy who prosecutors say was left lying in her own waste for days, ultimately dying from sepsis caused by severe, untreated wounds, according to court documents filed in Colonial Heights Circuit Court.
The arrests, which took place in December 2024, represent one of the largest single-facility criminal cases in recent Virginia nursing home history. Charges filed against the workers include felony abuse of a vulnerable adult, neglect, falsification of medical records, and obstruction of justice, as reported by Nurse.org.
How Court Records Exposed the Abuse
Search warrants filed in the case revealed text message exchanges between two Licensed Practical Nurses that paint a deeply troubling picture of the care culture inside the facility. According to court filings, the messages showed nurses openly discussing skipping medication administration for residents who could not speak up for themselves.
In one exchange cited in the warrants, a nurse described bypassing nonverbal patients during medication rounds, while a colleague acknowledged engaging in the same practice. The nurses also reportedly discussed giving sedating over-the-counter drugs to residents they described as difficult, according to investigators.
Perhaps most disturbing, court records indicate that one nurse shared a photograph of a patient through text message along with medical order information — the same patient who later died and is now at the center of the criminal investigation, as reported by WRTV.
Investigators also uncovered evidence that staff members documented care in facility records that was never actually provided — a dangerous practice known as false charting. According to the search warrants, documentation showed residents were billed daily for services that were never performed but were still recorded as completed, raising concerns about potential Medicare and Medicaid fraud.
The Victim's Final Days
The resident at the center of the case was a 74-year-old woman living with cerebral palsy and diabetes. According to prosecutors, staff left her in her bed for extended periods without turning or changing her, resulting in her lying in urine and feces until she developed severe flesh wounds. Those wounds led to a sepsis infection that ultimately caused her death, court documents state.
Prosecutors have also alleged that the woman suffered a broken foot and may have received incorrect medications that worsened her medical condition. One of the nurses involved has been charged with abuse of a vulnerable adult resulting in death, according to court records.
Following the investigation, the Virginia Department of Health barred the facility from admitting new residents. A 340-page state complaint filed against the facility outlined widespread problems including medication errors, poor infection control practices, and systemic failure to protect residents from harm, according to state health officials. Authorities have indicated the investigation remains active and additional charges and victims are expected.
CMS Inspection History
Federal inspection data from the Centers for Medicare and Medicaid Services reveals that Colonial Heights Rehabilitation and Nursing Center has carried the lowest possible overall rating of one star out of five — a designation that places it among the poorest-performing facilities in the nation. The 196-bed, for-profit facility also holds a one-star rating for health inspections and a one-star rating for staffing levels.
CMS records show the facility has accumulated 113 total deficiency citations across 14 inspections, reflecting a persistent pattern of regulatory noncompliance. During its most recent federal inspection in May 2023, surveyors cited the facility for failing to timely report suspected abuse, neglect, or theft, and for failing to respond appropriately to alleged violations — both classified at a Severity E level, indicating a pattern of noncompliance that caused actual harm or had potential to cause more than minimal harm.
That same inspection also flagged the facility for failing to ensure sufficient staff members with competencies to meet residents' behavioral health needs, another Severity E finding. Additional deficiencies included failures in care plan development and coordination with pre-admission screening programs.
The facility's quality measures rating of four stars stands in stark contrast to its inspection and staffing scores, a discrepancy that consumer advocates have noted can sometimes reflect data reporting issues rather than genuine quality of care.
Ownership & Operations
Colonial Heights Rehabilitation and Nursing Center operates as a for-profit limited liability company, according to CMS ownership records. The for-profit ownership model has faced increasing scrutiny from researchers and policymakers who have documented correlations between private equity and for-profit ownership structures and lower staffing levels in long-term care settings. Federal data confirms this facility's staffing rating sits at just one star, consistent with concerns about resource allocation at for-profit nursing homes.
The scope of the criminal charges — spanning 18 employees across multiple roles — suggests the problems at Colonial Heights extended well beyond individual bad actors. Investigators have indicated the pattern of false documentation and billing for unperformed services points to systemic operational failures that warrant continued scrutiny.
Resources for Families
Families with loved ones in Virginia long-term care facilities who suspect abuse, neglect, or inadequate care should contact the Virginia Long-Term Care Ombudsman program at 1-800-552-3402. Ombudsman advocates can investigate complaints confidentially and help families navigate the process of reporting concerns to state regulators.
The national Elder Care Locator hotline at 1-800-677-1116 connects callers with local services and reporting resources in any state. Additional information about residents' rights and how to file complaints is available through the National Long-Term Care Ombudsman Resource Center at ltcombudsman.org.
Federal regulations require nursing facilities to maintain adequate staffing, provide timely and appropriate medical care, protect residents from abuse and neglect, and accurately document all care provided. Families are encouraged to review their facility's inspection history and star ratings on Medicare's Care Compare website and to report any concerns promptly to both facility administrators and state authorities.
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