Case Explained: Addressing Nursing Home Abuse: Virginia’s Legal Challenges – Legal Perspective

by James C. Sherlock

The Virginia Department of Health (VDH) inspectors regularly report instances of resident abuse, including battery, occasionally resulting in death. That has persisted for decades and appears undeterred by current enforcement efforts.

The Code of Virginia (Code) is partially at fault. It makes it challenging for the state, its citizens, and local law enforcement to address dangerous deficiencies.

Long-term residents of nursing homes are expected to die there. Many short-term residents in skilled nursing beds are supposed to get better, but often do not. They instead return to the hospital or transition to long-term care or hospice.

Virginia law appears almost fatalistic in the face of those facts.

Multiple Code provisions governing the reporting and investigation of potential crimes in nursing homes are rendered incoherent by the proliferation of federal and state programs and sanctions.

• VDH personnel conduct federal and state inspections and investigate tips received on its complaints hotline and portal. The reports often cite violations of federal law that include evidence of crimes, including abuse, battery, or even manslaughter.
• The Centers for Medicare & Medicaid Services (CMS) has long been authorized by federal law to respond to those citations by sanctioning violators through administrative actions, such as fines or suspensions of new admissions. As of July 1, 2025, VDH also has sanctioning authorities.
• The Virginia Department of Social Services (VDSS) operates an Adult Protective Services (APS) program. APS investigates reports of abuse, neglect, or exploitation of adults aged 60 and older or incapacitated adults ages 18 to 59 submitted on its own hotline and portal .

Those parallel programs have not proven sufficient to mitigate recurring dangers to nursing home residents and, indeed, appear to be part of the problem.

The Colonial Heights Scandal

Action by criminal law enforcement in nursing homes is so rare that Virginians and their elected leaders were genuinely shocked when police, alerted and accompanied by APS, raided Colonial Heights Rehabilitation and Nursing Center (Colonial Heights) in December 2024.

The alleged events leading up to that death make a tragic story.

Police arrested and charged more than a dozen employees with felony abuse, neglect, and falsifying records to cover it up. Prosecutors allege that a helpless resident at the facility received inadequate care, resulting in pressure ulcers, skin lesions, sepsis, and ultimately her death.

As of March 2025, law enforcement had identified four additional victims. The investigation continues, presumably with an expanded scope.

Public shock, including among the General Assembly and Virginia’s federal elected officials, indicates how rare such cases are here.

State Agencies and Local Law Enforcement

The Colonial Heights raid is uncommon in considerable part because it is unclear under Virginia law when mandated reporters and the general public should contact either the VDH or APS hotlines, local law enforcement, or all three to report potential crimes in nursing homes.

The Code assumes coordination among them without requiring it. Virginia’s confusing non-system will not perform consistently as currently designed.

Reporting to and within the Executive Branch

The author apologizes in advance to readers for attempting to explain Virginia law on this matter. He admits he cannot. Examples:

§ 32.1-127.  Regulations (Effective January 1, 2026)

Paragraphs F, G, and H require the establishment of a workplace violence incident-reporting system for hospitals, but not for nursing homes.

Paragraph B.10.  addresses nursing home reporting requirements, but refers the Board to:

§ 63.2-1606.  Protection of aged or incapacitated adults; mandated and voluntary reporting

Paragraph A. requires mandatory and voluntary reports to be made to the local Department of Social Services or the state adult protective services hotline.

Paragraph B. clarifies that “nothing in this section shall be construed to eliminate or supersede any other obligation to report as required by law.”

Then it authorizes those providing professional services in a nursing home to notify facility management rather than report abuse to the state, presumably to avoid bruised feelings. It then requires nursing home managers to report on their own failures.

The rest of that law is similarly obtuse.

Deaths of residents

Virginia, like many other states, has provisions in law for both state and local Adult Fatality Review Teams to develop and implement procedures to ensure that adult deaths occurring in the Commonwealth are analyzed systematically.

The state’s 16-member team includes representatives from “attorneys for the Commonwealth, (and) law-enforcement agencies.”

Virginia has 17 local teams providing sporadic coverage of the Commonwealth’s cities and counties. In South Hampton Roads, only Norfolk has one.

Dying should not be a prerequisite for systematic investigations of evidence of crimes.

Bottom line

Provisions of the Code governing the reporting and investigation of potential crimes in Virginia nursing homes are, in many cases, functionally unworkable. Some pursue federal funding for specific voluntary programs, such as Adult Fatality Review Teams, which may not be helpful here. The Code should be rethought from start to finish on this matter.

Houston, Texas, employs a more comprehensive approach to Adult Fatality Review Teams.

Its Senior Justice Assessment Center (SJAC) integrates Adult Protective Services with a single, broader team that does not wait for a death to occur.  It:

Addresses the complex needs of senior (60 and older) victims of crime, abuse, neglect, and exploitation by collaborating with a team of experts in geriatric, forensic, and psychiatric medicine, civil and criminal prosecution, law enforcement, protective services, and social services.

Virginia lawmakers should consider it.