The inspection documents paint a critical picture: At Avante at Roanoke, an unannounced health and fire inspection turned up 34 deficiencies in 2007 -- more than four times the national average for for-profit nursing homes.

During unannounced visits to the facility, inspectors found a pattern of patients not being bathed often enough because of staff shortages, problems with cleanliness and at least two instances where residents faced immediate harm.

A new national study finds that such problems are not uncommon. Inspectors cited 94 percent of nursing homes last year for federal health and safety standards, the Department of Health and Human Services reported this week. The number of violations reported in Roanoke-area nursing homes, meanwhile, was higher than the national average in 13 out of 31 facilities.

The news came as no surprise to state and local senior advocates. "It's really disturbing, but unfortunately, it's not new," said Joani Latimer, Virginia's long-term care ombudsman.

Nationwide, about 17 percent of nursing homes had deficiencies that caused "actual harm" or put patients in "immediate jeopardy," the report noted, and for-profit homes were more likely to have citations than government-sponsored and nonprofit nursing homes.

"It's very, very much the same as past reports, and that's what advocates are so concerned about," Latimer added. "Some of these problems appear to be intractable."

Take bed sores, for instance. Last year, Virginia was ranked among the 10 worst states in the nation for high-risk pressure ulcers, she said, noting 2,260 instances.

"But until we get a better system that provides more direct-care staff and better-trained physicians, no matter what we do, it's not going to change," Latimer said.

At the Local Office on Aging's Area Agency on Aging, Ombudsman Pam McAdams receives about 40 calls a month from people concerned about their loved ones' nursing-home care.

McAdams does her own investigations and negotiates directly with nursing homes as needed while state investigators scrutinize the facilities annually in unannounced visits.

Steve Morrisette, president of the Virginia Health Care Association, the nursing home trade group, called the latest report a "data dump" and said it misleads families because it only talks about what is wrong in a facility, not what is right.

In the report, a minor infraction such as an inspector spotting a fly on the wall gets counted the same as a life-threatening mishap.

"I understand the public needs to know generally the quality of care that's provided in a nursing facility," Morrisette said. "But I'm not so sure the information coming out is in a form that really allows you to make an informed decision about placing a loved one there."

Virginia's Medicaid reimbursement rate is so low that facilities lose an average of $7 per day per Medicaid resident, he said. "And yet we have to meet the same 150 federal standards as nursing homes in other states, some of which get close to double the reimbursement."

Nearly two-thirds of Virginia's 27,000 nursing home residents are on Medicaid.

Avante at Roanoke, a 130-bed facility in the Old Southwest neighborhood, had the most violations, with 28 health-inspection infractions and six fire and safety deficiencies. Average daily certified nursing assistant time per patient at Avante was one hour, 40 minutes -- less than the region's top performer by 70 minutes.

According to more-detailed documents obtained by The Roanoke Times via the Virginia Freedom of Information Act, a September 2007 report included one isolated instance of actual harm, and another was deemed a case of immediate jeopardy.

Most of Avante's citations were judged as being less serious -- including one in which aides found two residents having sex when one of them was later deemed incompetent to provide informed consent.

The facility's management was roundly criticized in the document, "based on identification of immediate jeopardy of psychosocial needs along with deficiencies cited under: nursing staffing, not providing pain medication as ordered by the physician, failing to complete neurological assessments per facility policy after an unwitnessed fall, and failure to provide physician-ordered restorative treatments."

Lisa Wilson, Avante's regional director of operations in North Carolina and Virginia, would not address specific violations but did say: "The deficiencies were corrected, and we're in compliance with all of our regulations right now." The facility's current administrator is not the same one listed in the 2007 report.

The 180-bed Virginia Veterans Care Center had 26 health and three fire and safety violations. "The year before we had three or four total," said Bill Van Thiel, administrator of the Salem facility. "It's important to remember that any survey is pretty much a one-time snapshot, and there's a huge range in severity."

Although Van Thiel said he was not happy with 26 deficiencies, he stressed that none of his state-run facility's health violations was life-threatening. In one citation, a patient had yanked out his feeding tube without the staff's knowledge -- an isolated event.

The existence of bed sores is a much more telling gauge of facility excellence, he added. "Normally we run about three acquired bed sores for 180 patients; that's way under the national average [of 12.7 percent]. Today, I have none."

Though the number of violations nationally fell from 14,781 in 2005 to 14,394 in 2007, in Virginia the deficiency average increased 8.7 percent. Roanoke elder-law attorney Dan Frith believes the problems are greater than what was reflected in the report: "I hear so many complaints, especially about the for-profit homes." Frith asserts that profit-driven labor cuts are driving the gaps in care.

"I hear it over and over: 'We used to have five nurses working this wing, but now we have two CNAs and one nurse.' "

Vinton resident Ann Holloman, whose husband lives in an area nursing home, said she was not surprised by the findings. "There's room for improvement in all of them.

"You have to be vigilant, but it's also important to be supportive and to show your appreciation to the staff," said Holloman, who has been known to bake cakes for her husband's CNAs. "I know you've got CNAs and nurses who are so dedicated and work themselves to death, and I know they go home worn out."