Virginia health department reports detail hundreds of nursing home complaints

Virginia Department of Health inspectors walked into a memory care unit in Birchwood Park Rehabilitation and Nursing, a nursing home in Virginia Beach, in December. They found a distressing scene.

“The floor of the room was sticky and made a sucking sound as one walked across it, and the base board was peeling and drooping over in places,” read an inspectors’ report. “The floor was crusted with crumbs, brown debris, and black particles. The bed divider curtain had brown stains and smeared feces on it.”

The shower room was in a similar state, with visible mold, an odor of urine and feces, trash and debris littering the floor, a white crusted substance on the floor and walls, and used, brown-stained wet linens on the floor.

The memory unit had two occupants. One man, identified in the report as Resident 117, lie on a bed with only a sheet and no blanket. He wore no clothing and no gown; only a diaper soaked with urine.

“Please, please bring me some water — I’m so thirsty,” he repeatedly cried out, according to the report.

The report states staff didn’t bring the man water or any food between 9 a.m. and 5 p.m. that day. When asked why not, the certified nursing assistant on duty said the man was on hospice and didn’t want that. State inspectors did not observe the man out of bed at any point during the three-day survey.

Birchwood Park did not respond to multiple requests for comment.

The inspection was carried out after a complaint was filed with the VDH. It’s an example of a growing number of nursing home complaints — so many the state cannot keep pace. The health department investigated 285 nursing home complaints this year.

The results of those investigations are published in Statements of Deficiency and Plans for Correction, which were obtained by The Virginian-Pilot through a Freedom of Information Act request. Some of those reports from nursing homes in Hampton Roads are highlighted here:

What the investigation found

At Birchwood Park, Resident 117’s roommate, identified as Resident 226, said he was in the memory care unit against his will. The unit is typically reserved for people diagnosed with dementia, which Resident 226 did not have. He told inspectors that there were no TVs or even clocks on the wall, and that he hated the place but had nowhere else to go.

“Everyone is crazy in here, they wander into my room and take things, my roommate yells and cries all night for something to drink, I don’t even get food every meal, the room is nasty and falling apart, and I can’t even get a shower in here because the showers are so nasty dirty,” he told inspectors.

The report includes summaries of interviews with staff. Employees told inspectors Resident 226 had been placed in the unit as a result of “wandering behaviors.”

“When asked what his behaviors were, they were only able to say he went outside and sat in his wheel chair one time after dialysis, and further stated he would ‘wander up and down the halls’ and ‘that will get you put in here for sure,’ ” the report read.

The interviews with employees revealed that staffing had been tight, with nine employees in environmental services working at a time for 122 residents. Two dryers had been broken for months, leaving just one dryer operating 24 hours a day, resulting in a backup of dirty linens and pervasive odors of urine and feces.

The statements of deficiency also include plans of corrective action to be take by the facilities. At Birchwood Park, the shower room tile was replaced and the walls and rails were cleaned. Pictures for the walls, clocks and TVs were ordered. The Director of Environmental Services was scheduled to educate housekeeping and maintenance staff on correcting repairs and cleanliness issues.

The report also states that Resident 226 moved out of the memory care unit per his request. Resident 117 was ultimately discharged a few weeks later.

Nursing home complaints on the rise

The number of nursing home complaints increased by nearly 60% between 2018 and 2024, according to a presentation State Health Commissioner Karen Shelton delivered last month to the Joint Commission on Health Care. As of July, the VDH received 944 complaints in 2025, more than all last year.