Portsmouth Health and Rehab: Abuse Reporting Failures - VA
When federal inspectors arrived at the facility at 900 London Boulevard this past September, what they found wasn't a mystery about whether the abuse had happened. The nurse who did it admitted it. The nurse who saw it confirmed it. The resident's account matched both of theirs. What inspectors documented was something different: a reporting system that broke down at almost every level before anyone with actual authority knew what had occurred.
The incident happened on the night of March 23, 2025. A resident identified in inspection records only as R53 had become agitated after receiving his medications. According to LPN14, the nurse involved, R53 came at her in the hallway with a wet floor sign and cursed at her near the medication cart. LPN14 confirmed to inspectors on September 18 that she picked up the water pitcher and told him she would crack him in the head if he didn't back off.
LPN1, who witnessed the confrontation, described the scene from her vantage point: LPN14 standing at the medication cart with a water pitcher in her hand, R53 in his wheelchair in front of her, screaming, the wet floor sign in his grip.
What LPN14 did next is not in dispute. She wrote a statement at LPN1's request and left the facility for the evening. She verbally quit. She did not return until March 25, when she came back to give a second statement to the administrator. She was terminated that day.
LPN1 reported the abuse to the on-call manager around 11:00 PM on March 23. She told inspectors she couldn't remember the manager's name. The on-call manager instructed her to write a statement and to obtain one from LPN14. LPN1 told inspectors she believed she had reported timely. She had done what she was told. Whether anyone above her acted on it that night is a different question.
The administrator confirmed to inspectors on September 17 that she was not notified of the verbal abuse when LPN1 reported it to the on-call manager on the night of March 23. She learned about it not through any chain of command but because LPN1 left a concern note on March 25, nearly two full days after the incident. That note is what finally moved the administrator to act.
Once she knew, the administrator moved quickly. She submitted the initial report to the state survey agency on March 25. She initiated the investigation. She asked LPN14 to write a statement. By April 3, she had substantiated the abuse in the five-day follow-up report. Staff training on abuse, neglect, and reporting followed.
But the required timeline had already been missed. The administrator confirmed she did not report the incident to the state within two hours of it occurring, as required. She did not submit the initial report within the required timeframe. The five-day follow-up report was also late.
The on-call manager, whoever that person was, received a direct report of witnessed abuse from a licensed nurse at 11:00 PM on a Sunday night. The administrator was not notified. There is no indication in the inspection record that the on-call manager escalated the information to anyone before the administrator found out through a handwritten note two days later.
LPN14's account of what provoked her is worth considering alongside what she admitted. She told inspectors that R53 came at her with a wet floor sign and cursed at her after she gave him his medications. She described feeling threatened. None of that changes what she did next or how the facility handled what followed. The administrator substantiated the abuse. LPN14 was fired. The investigation reached the conclusion the facts supported.
What the inspection documents is the gap between when the abuse occurred and when the people responsible for reporting it actually did. LPN1 reported to the on-call manager at 11:00 PM. The on-call manager, by the administrator's own account, did not pass that information up the chain. The administrator found out because a nurse left a note. The state found out because the administrator filed a report, two days late.
The violation cited is F0609, covering the facility's obligation to report alleged violations, including abuse, to the state survey agency within required timeframes and to conduct proper investigations. Inspectors rated the level of harm as minimal harm or potential for actual harm, with few residents affected. LPN14's suspension during the investigation and her termination on March 25 are noted in the record.
What the record does not contain is any account from the on-call manager, whose name LPN1 could not recall and whose decision not to notify the administrator sits at the center of how a witnessed, reported incident of verbal abuse went unreported to the state for two days. That person received the information first. That person gave instructions. That person is not identified by name in the inspection report, and inspectors did not appear to have interviewed them, or if they did, no account appears in the narrative.
R53 was in his wheelchair in the hallway, screaming, holding a wet floor sign, when a nurse raised a water pitcher over him and told him what she would do with it. Someone saw it. Someone reported it. And the system that was supposed to move that information upward and outward, to the administrator and then to the state, stopped somewhere in the night between a phone call to an on-call manager and a handwritten note left two days later.
The administrator confirmed all of it. The training happened. The nurse was fired. The reports were filed, late. Whether the on-call manager who received the first call that night still works at Portsmouth Health and Rehab is not addressed anywhere in the inspection record.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Portsmouth Health and Rehab from 2025-09-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 27, 2026 · Our methodology
PORTSMOUTH HEALTH AND REHAB in PORTSMOUTH, VA was cited for abuse-related violations during a health inspection on September 19, 2025.
The nurse who did it admitted it.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.