All the details in our Health Safety stories come from publicly available Final Orders, Consent Orders, Orders of Suspension and other documents from the Virginia Department of Health and other government agencies. For more information, see the Editor’s note below the story.
In 2021, an elderly, bedridden resident at the Petersburg-based nursing home Battlefield Park HealthCare Center was panicking. An employee of the Centers for Medicare and Medicaid Services (CMS) −a federal agency within the United States Department of Health and Human Services (DHHS) − was conducting an inspection of the facility and could hear her desperately calling for help, stating that she couldn't breathe. The inspector noticed that a nurse could hear the resident, but ignored her pleas for help because she was on her lunch break. The patient called out for help for over half an hour before anyone came to her aid.
When people send their loved ones to nursing homes, they expect them to be treated with dignity, care and respect. Not only did Petersburg nursing home Battlefield Park Healthcare Center fail to meet these standards during multiple inspections throughout the years, but the granddaughter of one recent former resident said her grandmother was lucky to escape the nursing home with her life.
For over a week in March 2018, CMS employees conducted several unannounced surveys at Battlefield Park. They found dozens of deficiencies at the facility and determined that “significant corrections” would be necessary to bring the nursing home into compliance with state and federal law. The CMS wrote up the nursing home for over 30 different deficiencies, noting issues with the facility’s emergency preparedness plan as well as the day-to-day quality of care given to patients, which they described as “substandard.”
The CMS found that the facility was failing to treat some residents with dignity and respect and even endangering others. At least one resident had been left to lie in his own urine for hours. In multiple cases, the nursing home endangered residents by giving them incorrect medications or failing to give them their medications at all. Several times, Battlefield Park ran out of antibiotics altogether. They failed to keep complete and accurate clinical records, mixed up residents' medical records and failed to meet “professional standards of quality” care. They even failed to properly feed multiple patients, including failing to administer correct tube feeding to elderly residents and giving one an expired tube feeding bottle.
They failed to prepare and serve food in a safe and sanitary manner. They failed to provide multiple residents, including a patient with suicidal ideation, with the necessary behavioral and mental health care required by law. They failed to develop comprehensive care plans for residents in multiple cases, also required by law, and failed to provide adequate supervision to prevent accidents, resulting in multiple injuries to elderly residents. At least two were burnt with hot liquids. Another fell and fractured her leg while staff was transferring her without taking the necessary precautions. Other residents developed preventable ulcers because facility staff failed to take necessary precautions.
They also failed to stop abusive behavior when at least three residents were being physically and verbally abused for months by another resident with the knowledge of facility staff and administrators. Staff did not step in to stop the abuse, investigate it or report it, nor did they put a plan into place to prevent it in the future − all of which is required by law. Instead, the abuse continued for months, resulting in injuries to multiple elderly residents, until a CMS inspector intervened.
CMS ordered the nursing home to provide a corrective plan for it's deficiencies, which it did— without acknowledging any responsibility.
“This plan of correction is prepared and executed because it is required by the provisions of state and federal law and not because Battlefield Park HealthCare Center admits or denies the validity of the allegations and citations listed...” their response stated. “…Battlefield Park HealthCare Center maintains that the alleged deficiencies do not jeopardize the health and safety of the residents, nor...limit our capability to render adequate care.”
CMS made another surprise visit to the facility in 2019. They reported even more deficiencies than they had in 2018—including many of the same deficiencies from 2018 that hadn’t been resolved. Some of these deficiencies resulted in serious harm to residents, including bedsores, severe malnutrition, lacerations, fractures, a head injury and more.
A 2021 inspection seemed to show improvement − 10 deficiencies instead of 35. But the deficiencies found still posed a serious risk to some residents. The facility failed to properly assess multiple residents’ cognitive function and properly screen some residents for mental disorders and intellectual disabilities. They failed to background check, check references for or perform professional license verifications on employees as is required by law, putting residents at risk. And they failed to provide proper care and assistance to at least one resident during the CMS inspectors’ visit—the elderly, bedridden resident who spent over half an hour calling for help but was ignored by a nurse because she was on her lunch break.
Despite less deficiencies being reported at Battlefield Park in 2021, not much seems to have changed since 2018. The facility’s recent online reviews complain of rude and unprofessional staff, elderly residents being left in soiled clothes or bedsheets for prolonged periods of time, residents not being fed or given their medication on time, a constant stench of urine and more.
Stephanie Moiczek, 49, sent her grandmother to receive physical therapy at Battlefield Park in February 2024 after a fall and a bad UTI. She said her grandmother received no such care. Instead, Moiczek said staff left her grandmother to languish in bed for days at a time during her week and a half stay − sometimes in soiled clothes and bedsheets − and let her develop bed sores. At one point, she fell out of bed and was hospitalized for her injuries, which included a bump on her head that left a nasty bruise. Worst of all, she said, the facility gave her grandmother four times the prescribed dosage of her blood pressure medication every day throughout the duration of her stay, leaving her dizzy, unstable on her feet and with a dangerously low blood pressure of 64/43.
“We’re very lucky that she didn’t leave in a body bag” Moiczek said. “… If you want your loved one to survive their rehab and not get hurt or injured or neglected in the process, avoid this place at all costs.”
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To file a formal complaint against a health professional, click here . For links to the public information informing this story, see below.
Want to know if your doctors, other medical professionals or local pharmacies have been investigated? Check out the license lookup.
EDITOR’S NOTE: When citizens are a danger to the public safety, law enforcement arrests them and charges them with crimes; they have the opportunity to face a jury of their peers; if convicted, they serve time and/or probation that can often ensnare them in the system for years.
When a medical professional is an alleged danger to the public safety, the Virginia Department of Health Professionals handles all facets of the inquiry, including the investigation and penalties. And sometimes, even when a medical professional is found liable of doing harm to patients, they may face a reprimand, pay a fine and continue to practice, without missing a day of work and with little chance for the public to see what they’ve done.
The Health Safety stories in this series tell the facts of cases where medical professionals endanger our public health safety. They also bring you into the world of the medical board’s consent orders and public final orders, so you can see exactly how the VDHP’s self-policing system works.
LINKS TO DOCUMENTS REFERENCED ABOVE:
Battlefield Park Healthcare Center License Number: NH-0002494
This article originally appeared on The Progress-Index: 'Lucky she didn’t leave in a body bag': Local nursing home endangered residents for years.
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