Resident 106 told federal inspectors in September that nobody offered him another room on December 17, 2024, when his roommate died at 5:20 PM. The body remained in the shared room until funeral home staff collected it at 10:11 PM, according to facility death records.
The 83-year-old resident had been admitted earlier that year and scored a perfect 15 out of 15 on cognitive assessments, indicating he was mentally intact and fully aware of his surroundings. He could walk independently and understood what was happening around him.
Multiple facility staff members confirmed to inspectors that Portsmouth Health and Rehab had an established policy requiring staff to offer surviving roommates either diversional activities outside the room or relocation to another room when a death occurred. Nobody followed that policy.
"We do not have a specific policy for dignity," Administrator admitted during questioning on September 18, 2025.
The Central Supply Manager, who was assigned to Resident 106's room to "ensure everything was in place" after the death, could not remember whether the body remained in the room but acknowledged the facility policy to offer the living resident another room. She had not done so.
Licensed Practical Nurse 9, an agency staff member working that day, told inspectors that when a resident dies, staff are supposed to "pull the curtain and offer any roommate another room." The curtain was pulled. The room offer never came.
The MDS Coordinator, who pronounced Resident 119's death, said she was responsible only for the death pronouncement and was not the staff member designated to speak with Resident 106 about moving. She confirmed the facility policy existed but could not explain why nobody else had handled the required conversation.
Resident 106's medical records contain no documentation that staff offered him a room change on December 17. Progress notes from that date make no mention of any attempt to address his wellbeing or provide alternatives during the traumatic event.
The Administrator described the standard process to inspectors: offer the surviving roommate "outside diversional activities or another room." When pressed about why this did not happen with Resident 106, the Administrator could not provide an explanation.
Federal inspectors classified the violation as having "minimal harm or potential for actual harm" but noted it affected a "vulnerable resident" who could have been traumatized by the experience. The finding represents a failure to honor the resident's right to dignified treatment.
Resident 106 had been living at Portsmouth Health and Rehab for several months when his roommate died. His admission assessment showed he was physically capable, mentally sharp, and able to communicate his needs clearly. These factors made the facility's failure to offer him basic dignity protections during a distressing situation particularly egregious.
The inspection occurred nine months after the December incident, following a complaint about the facility's handling of the situation. Inspectors reviewed medical records for four residents as part of their activities assessment but found the dignity violation affected only Resident 106.
Portsmouth Health and Rehab operates at 900 London Boulevard in Portsmouth, serving dozens of residents who depend on staff to follow established policies designed to protect their wellbeing during difficult circumstances.
The facility's own staff acknowledged the policy existed and was well-known among employees. The Administrator confirmed the standard procedure. The MDS Coordinator recognized the requirement. The Licensed Practical Nurse understood the protocol.
Nobody followed it.
Resident 106 remained in his room from 5:20 PM, when his roommate died, until after 10:11 PM, when funeral home staff removed the body. For nearly five hours, he experienced what federal regulations classify as a violation of his right to dignified treatment.
The inspection report provides no indication that any staff member checked on Resident 106's emotional state during those hours or offered support services. No documentation suggests anyone considered the psychological impact on a cognitively intact resident of remaining in close quarters with his deceased roommate.
The Administrator's admission that Portsmouth Health and Rehab lacks "a specific policy for dignity" reveals a broader institutional gap in protecting residents' basic human rights during vulnerable moments. Federal regulations require facilities to honor residents' rights to dignified existence, but this facility appeared to lack concrete procedures for implementing that standard.
The violation occurred despite multiple layers of staff oversight. The Central Supply Manager was specifically assigned to the room. The MDS Coordinator handled the death pronouncement. Licensed nursing staff were present and aware of protocols. The Administrator knew the policy requirements.
Each staff member understood their role in the established procedure. None ensured Resident 106 received the basic consideration the facility's own policies demanded.
The December 17 incident represents more than a paperwork oversight or communication breakdown. A vulnerable resident experienced hours of potential trauma because staff failed to implement a straightforward policy designed specifically to prevent such situations.
Resident 106 continues living at Portsmouth Health and Rehab, where staff now know federal inspectors documented their failure to protect his dignity during one of the most distressing experiences a nursing home resident can face.
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.