Here is a sample of the 108 Nursing Homes on the Abuse Watch and the revenue they take in. Bayside of Poquoson Health and Rehab – Poquoson, VA $ 8,166,177.00 Hampton Health & Rehab Center, Llc - Hampton $ 17,677,001.00 Coliseum Convalescent and Rehab Center - Hampton $ 18,113,305.00 Regency Health and Rehab Center – Yorktown $ 8,314,337.00 Waterview Health and Rehab Center – Hampton $ 22,701,859.00 Newport News Nursing and Rehab -NN $ 11,604,047.00 Pelican Health Norfolk – Norfolk $ 6,540,275.00 Signature Healthcare of Norfolk – Norfolk $18,697,951.00 Norfolk Health and Rehab Center – Norfolk $18,957,443.00 Portsmouth Health and Rehab – Portsmouth $ 13,616,894.00 Pelican Health Virginia Beach – Virginia Beach $ 9,047,156.00 Bayside Health and Rehab Center – VB $ 9,807,607.00 Portside Health and Rehab – Portsmouth $ 4,612,219.00 Accordius Health at River Pointe Llc – VB $ 6,618,990.00 Envoy of Williamsburg, Llc – Williamsburg $12,082,580.00 The Citadel Virginia Beach – Virginia Beach $4,616,078.00 Greenbrier Regional Medical Ct – Chesapeake $8,268,625.00 Kempsville Health & Rehab Center – VB $10,261,874.00 Rosemont Health & Rehab Center, Llc – VB $16,456,175.00 Consulate Healthcare of Williamsburg – $10,910,271.00 Virginia Beach Healthcare and Rehab Center – Virginia Beach $ 24,351,036.00 Colonial Health & Rehab Center Llc – VB $17,004,872.00 Chesapeake Health and Rehab Center – Chesapeake $22,104,190.00 Autumn Care of Suffolk – Suffolk $10,336,944.00 Consulate Health Care of Windsor – Windsor $ 11,975,691.00 Dockside Health & Rehab Center – Locust Hill $ 5,081,796.00 Riverside Conval Center – Saluda Three Rivers Health & Rehab Center – West Point $ 11,189,512.00 Lancashire Convalescent and Rehab Center – Kilmarnock $ 8,280,359.00 Accordius Health at Courtland – Courtland $ 8,703,172.00 River View On The Appomattox Health & Rehab Center – Hopewell $ 16,128,641.00 Wonder City Rehabilitation and Nursing Center – Hopewell $ 11,290,873.00 Battlefield Park Healthcare Center – Petersburg $ 12,200,971.00 Petersburg Healthcare Center – Petersburg $ 11,804,224.00 Colonial Heights Rehab and Nursing Center – Chesterfield $ 21,103,000.00 Henrico Health and Rehab Center – Highland Springs $ 17,476,151.00 Carrington Place of Tappahannock – Tappahannock $ 6,252,241.00 Dinwiddie Health and Rehab – Petersburg $ 9,011,656.00 Hanover Health and Rehab Center – Mechanicsville $ 19,165,246.00 Autumn Care of Mechanicsville – Mechanicsville $ 22,938,075.00 Envoy of Westover Hills – Richmond $ 15,458,233.00 Manorcare Health Services Imperial – Richmond 31-May-19 $ 16,292,794.00 Total $ 1,085,735,970.00

The Joint Commission on Health Care reported on Oct 5th, 2021 that about one-fifth of Virginia’s nursing homes do not meet CMS expectations for staff hours. The actual numbers are unfortunately much higher. There are currently 108 Virginia Nursing Homes listed on the Nursing Home Abuse Watch list. These homes provide less than 2 hours of care per resident per day when more than 90% of the residents need assistance with incontinent care, transferring to a wheelchair or bed and have dementia. They also have very high revenues in spite of this poor care. NHAA Hotline https://nursinghomesabuseadvocate.com/WATCHLIST/ NHAA (Nursing Homes Abuse Advocates) is a 501(c)(3) non-profit that gathers information about nursing home abuse, neglect, and unsafe practices. NHAA collects and makes available investigations conducted by state and federal nursing home inspectors. In addition, NHAA receives and processes complaints made about nursing homes across the United States from families of residents. Information is compiled on every nursing home with a reported problem and is made available to the public. Our interview process allows the community to participate without fear and allows callers to volunteer information anonymously. Our research and services are free. Our mission is to provide the public with updated information about abuse, neglect, and unsafe practices so that you can make educated decisions about: choosing a facility, remaining in a facility where there are unresolved complaints, and/or what actions can be taken on behalf of neglected or deceased nursing home residents. Nursing Home Watchlist What gets a nursing home on the list? In order to be on the Watchlist a facility must have one or more of the following. Actual Harm: The facility caused serious harm or injury, impairment or in the worst case, death of a resident. – found by State investigators in published inspections History of Actual Harm: The facility has a history of at least 5 actual harm findings. Special Focus Facility: The facility has a history of serious quality issues. – as determined by the Center for Medicare and Medicaid Services Unsafe Staffing: The facility’s staffing levels are consistently below those levels necessary to avoid patient harm and ensure delivery of care. – as determined by the Center for Medicare and Medicaid Services, Institute of Medicine, and American Nurses Association Worst Ratings: The facility repeatedly received the worst possible rating for one or more of the following: Overall Rating Health Inspection Rating Quality Rating Staffing Rating RN Staffing Rating – as determined by the Centers for Medicare and Medicaid Services

To the members of the JCHC Nursing Facility Workforce work group; Thank you for the opportunity to contribute towards this worthwhile discussion. I am a physician who works full time in long term care and skilled rehab and feel truly honored to work with elders all day, every day. I am fortunate to be medical director for 2 excellent facilities in Richmond – Our Lady of Hope and Westminster Canterbury. I hold a PhD from VCU Medical Center and a Masters of Arts in Theological Studies from Union Presbyterian Seminary. You may know me as the former medical director of Canterbury Rehabilitation and Healthcare Center (not to be confused with Westminster Canterbury). Canterbury is one of the many Virginia nursing homes with staffing ratings of 2 stars or less. During my tenure at Canterbury, its overall quality rating remained around 1-2 stars. Projects I initiated to improve quality and protocols I established to ensure safety foundered in the face of not only low staffing but staffing turnover rates that reached over 100%. In March of 2020, Canterbury became the first facility in Virginia with an outbreak of COVID-19, an outbreak that eventually took the lives of 51 of my patients. As you point out on page 7, lower staffing has long been linked to lower quality of care. During the pandemic, studies also showed that facilities with a history of lower staffing were also linked to higher mortality from COVID-19. I certainly saw this at Canterbury. The Nursing Facility Workforce work group is meeting at a critical time in the history of long term care in Virginia. As you point out, residents of publicly-funded nursing homes have long suffered from staffing shortages, and much of this suffering has been borne by our poorer residents and residents of color – those supported by Medicaid. Prior to COVID-19, that suffering was manifested in such things as higher frequencies of bed sores, infections, and anti-psychotic use. After the COVID pandemic, however, we know that understaffing is not just a matter of quality, it’s a matter of life and death. In recognition of the urgency of this matter, and in hopes that lessons learned during the COVID pandemic will result in safer, better staffed nursing homes, I firmly support the following Options: Option 1: Increase Medicaid funding: this is the bedrock of any improvement in staffing. We can see this in how staffing ratios improve as a facility has lower rates of Medicaid patients Option 2: Set minimum staffing ratios for all nursing homes: although there are arguments to be made in favor of tying staffing to acuity levels (Option 3), many states – see New York’s recent Safe Staffing bill – realize that the complexities and costs of determining acuity levels further eat into the scarce resources available to nursing homes. In such an urgent situation, setting minimum staffing ratios for all nursing homes will do the most good for the most at risk residents. Option 8: increasing reimbursement rates for resident with behavioral problems: Nursing homes serve as the homes of last resort for poor people with mental health problems. Caring for these people takes more staffing time, sometimes requiring one-on-one care. If appropriate staff is not available, many providers are forced to use medications to sedate people who really just need something to do. Increasing reimbursement could not only increase staffing, but could improve activities and enhance the physical space in which we confine them.

Dear JCHC members, Thank you for allowing me to submit comments on this study. I am a medical director and physician practicing exclusively in skilled nursing and long-term care medicine. Also, while I am employed by VCU and MCVP, the opinions listed in this letter are my own and do not reflect the beliefs of my employers or the Commonwealth of Virginia. The current staffing shortage and issues around workforce supply in Virginia for nursing homes did not start with COVID-19. Being a frontline nurse (whether a nurse aide, an LPN, or an RN) in nursing homes is physically, intellectually, and emotionally challenging. It is important to separate the effect of COVID-19 on this long-standing clinical issue. AMDA – The Society of Post-Acute and Long-Term Care Medicine is a national professional association that represents and supports clinicians and related professionals who work in nursing homes, long-term care, assisted living, home care, hospice, and other settings. AMDA recognizes that while having a sufficient number of staff is critical, staffing levels based only on resident-to-worker ratios will not adequately assess or meet resident needs. Any decisions about staffing need to consider the broader issues, including: • the complexity and acuity of a facility’s population; • the functional level of residents and services required; • defining and including other categories of caregivers, such as medication aides, feeding assistants, restorative aides, family members, and activities professionals; • the quality, competence, and engagement of staff leadership and supervision; • addressing adequacy of training and skills development, and • the career and educational development of staff It is with this background in mind that I wish to comment on 3 potential options outlined in the study resolution document prepared by the JCHC. • Option 3 – I am in favor of linking staffing to resident acuity but practically, how would this be carried out inside the facility? • Option 6 – I like the idea of considering funding a pilot program to look at workforce issues and sense of community. In making this decision, please make sure that whatever project is funded that key stakeholders are present. Ideally, such a program would have oversight from a steering committee composed of nursing home clinicians, nurses, and administrators. • Option 8 – This is perhaps my favorite option. Dementia, Depression, and Delirium and 3 key diagnoses that impact the lives of frontline staff, residents, and families. These are challenging conditions to manage non-pharmacologically and require extra staff on hand. If we could review and support the care and staff training requirements in homes that have a high proportion of these conditions, it would be very valuable to all involved. Lastly, in closing, I just want to congratulate the JCHC staff including Jeff Lunardi and Kyu Kang, the JCHC members, as well as the Virginia General Assembly for working through this study and highlighting this important issue. I hope that my comments are helpful and I recognize that you have difficult decisions to make. We appreciate your public service and know you will ultimately make the right decision. Think progressively. Be bold. Be compassionate. Thank you, Christian Carl J. “Christian” Bergman, MD, CMD Assistant Professor, Division of Geriatric Medicine, Virginia Commonwealth University Email: Carl.Bergman@vcuhealth.org