Portsmouth Health and Rehab: Discontinued Narcotic Given - VA
The resident, identified in inspection records only as Resident 13, was admitted to the facility with epilepsy and a history of status epilepticus, a condition in which seizures chain together without full recovery between them. He had an order on file for lorazepam, the brand-name drug Ativan, to be used once for agitation or combative behavior. That order was not for seizures. And by the time he needed it, the order had been discontinued entirely.
A certified nursing assistant found him in bed in visible distress and called for a nurse. A licensed practical nurse, identified in the report as LPN5, responded, found him seizing, and called 911. The seizure ran four minutes, stopped for ten seconds, then started again for five more minutes. A registered nurse, identified as RN2, arrived and noticed the Ativan still sitting in the narcotic drawer on the medication cart. She knew the order was discontinued. She administered it anyway, injecting 0.5 cubic centimeters into his right deltoid muscle.
The medication should not have been in that drawer. Under the facility's own policy, discontinued controlled substances are supposed to be pulled from the cart immediately, logged on a controlled drug sheet, secured in a double-locked area, and destroyed by the director of nursing alongside another nurse. None of that had happened.
The facility's internal investigation confirmed what the inspection report later documented: the lorazepam had been discontinued, there was no active order, and RN2 administered it knowing both of those things. LPN5 was suspended the same day the investigation opened and terminated shortly after. RN2 was removed from the schedule, and the staffing agency that placed her was told she was not to return to the facility.
DON2, a director of nursing who had been at the facility only a couple of weeks when the incident occurred, led the investigation. She told inspectors she reviewed the narcotic drawers on the medication carts after the incident and found additional discontinued and expired controlled medications that had never been pulled. She destroyed them with the unit managers after the fact.
What she found suggests the problem was not isolated to one overlooked vial. Discontinued narcotics sitting in medication carts, unlogged and undestroyed, across multiple units.
The first director of nursing, identified as DON1, told inspectors that discontinued narcotic medications should be pulled from the cart along with a completed narcotic sheet and brought to her for destruction with another nurse present. She described the process as it was supposed to work. The investigation found it had not been working that way.
The administrator told inspectors that DON2 handled the investigation and the subsequent destruction of the controlled medications with unit managers. The re-education of all nursing staff on physician orders, medication administration, and the narcotic destruction process for discontinued drugs was completed by DON2 on a date redacted from the public record.
Federal inspectors rated the harm to Resident 13 as minimal, a classification that accounts for the fact that lorazepam is a standard treatment for seizures and may have helped him. But the rating does not address what would have happened if the medication in that drawer had been something else, or if the wrong dose had been drawn, or if the next discontinued drug left sitting in a cart were pulled out under different circumstances with a different outcome.
The inspection was triggered by a complaint. It covered a sample of 47 residents, and inspectors identified this violation in their review of pharmacy services for four of them.
Resident 13 seized for nearly ten minutes in his bed before a nurse made the decision to use a drug she knew she had no order to give. The drug worked, or at least the seizure stopped. But the medication had been sitting in that drawer, unaccounted for and undestroyed, because no one had followed the process that existed specifically to prevent this from happening.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 14, 2026 · Our methodology
PORTSMOUTH HEALTH AND REHAB in PORTSMOUTH, VA was cited for violations during a health inspection on September 19, 2025.
He had an order on file for lorazepam, the brand-name drug Ativan, to be used once for agitation or combative behavior.
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.