Westport Rehab: Care Plan Left Wrong for Paralyzed Man - VA
The instruction sat in his file, uncorrected, while nurses who cared for him daily knew it was wrong.
The resident, identified in inspection records only as R1, was admitted to Westport with paraplegia, cardiovascular disease, and a bladder condition requiring a catheter. A federal assessment completed in late September 2025 confirmed what his nurses already knew: he had not attempted to walk ten feet, and the reason listed was medical condition or safety concerns. For mobility, he depended entirely on staff. He used a wheelchair.
His care plan, last revised September 27, 2025, said otherwise. Under fall prevention interventions, it instructed staff to ensure the resident wears shoes when ambulating, to place common items within his reach, and to remind him to use his call light when he needed help with daily activities. The shoe instruction assumed a man who moved through the facility on his own two feet.
He did not.
A licensed practical nurse who cared for R1 told inspectors she remembered him clearly. He could not walk, she said, and he had a catheter. She had changed his catheter and catheter bag when a nurse practitioner asked her to, the last time before he was transferred to the hospital. His sister had been visiting that day.
When an inspector asked her whether the care plan intervention about shoes was accurate, she did not hesitate. No, she said, because he did not walk. When asked whether the care plan should have been revised, she said yes.
A second nurse, interviewed the following morning, said the same thing without prompting. She remembered R1 as someone who could not walk and used a wheelchair.
Both nurses understood the care plan was wrong. Neither had changed it. The facility had not changed it either, even after revising the document in September.
The care plan itself was not a minor administrative form. When the inspector asked the first nurse to explain its purpose, she gave a precise answer: it describes the care each resident needs and what interventions staff are to implement to meet those needs. That is exactly what a care plan is supposed to do. In R1's case, it described interventions for a version of him that did not exist.
The inspection, a complaint survey, was completed October 22, 2025. That morning, the director of nursing, the facility administrator, and the assistant director of nursing were told what inspectors had found. No additional information was provided before the survey team left the building.
R1 was not at Westport when inspectors arrived. He had been transferred to a hospital before the survey began. The inspection report does not say why he was hospitalized, or whether the errors in his care plan had any connection to what happened to him.
Federal inspectors rated the violation as causing minimal harm or potential for actual harm, the lowest level on the harm scale. The finding applied to a small number of residents.
What the record shows is a man with paraplegia whose care plan told staff to watch his footwear when he walked. Two nurses who worked with him knew it was wrong. The document stayed wrong anyway.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westport Rehabilitation and Nursing Center from 2025-10-22 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 24, 2026 · Our methodology
WESTPORT REHABILITATION AND NURSING CENTER in RICHMOND, VA was cited for violations during a health inspection on October 22, 2025.
The instruction sat in his file, uncorrected, while nurses who cared for him daily knew it was wrong.
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.