Westport Rehab: Undocumented 911 Call, Insulin Gaps - VA
The incident involving the resident identified in inspection records as R4 occurred on or around January 27, 2025, the same day the nurse assigned to his unit was suspended and sent home. A unit manager had stepped in to cover. When R4 began showing what staff described as "behaviors," a licensed practical nurse, identified in the report as LPN #3, was called outside to try to bring him back in.
LPN #3 told inspectors she found R4 upset and confused near the road. She called a family member and tried to get R4 to speak with them. He refused. He then used his own phone to dial 911. When police arrived, they also tried to convince him to return to the building. He refused that too. LPN #3 said she eventually went back inside. She later watched R4 being loaded into an ambulance. The former administrator, she said, was standing outside at the time.
The director of nursing told inspectors she had been informed that R4 "went outside and called 911 themselves and initiated the hospital transfer themselves," as though the resident's own action closed the matter. It did not. LPN #3 was direct about what should have happened regardless: staff were supposed to document the incident in the medical record, notify the physician, and notify the responsible party. None of that occurred.
The facility had no documentation of the incident in R4's chart. No nursing note. No physician notification. No record that anyone in a clinical role had assessed what had happened or communicated it to the people responsible for R4's ongoing care.
The inspection report cites a nursing fundamentals textbook to make the point plain: if an assessment finding or problem is not recorded, it is lost and unavailable to anyone else caring for the patient. Observation and recording, the text states, is a legal and professional responsibility.
The documentation failure was not the only problem inspectors found with R4's care.
He had two active insulin orders for Type 1 diabetes, a condition in which the body produces no insulin on its own and requires it to survive. One order, for Insulin Lispro given on a sliding scale based on blood sugar readings, had been in place since June 2024. A second order, for Admelog SoloStar, was added January 22, 2025. The medication administration records show R4 received the Lispro doses as ordered through the morning of January 24. The Admelog, however, was scheduled to begin January 22 at 6:30 AM and was not given until 4:30 PM on January 24, more than two days later.
The notes entered in the electronic medication record for those missed doses said staff were waiting for clarification from the nurse practitioner.
LPN #7 told inspectors that when questions arose about a medication, staff called the physician or nurse practitioner to clarify. That is what should have happened. On October 22, 2025, the director of nursing acknowledged to inspectors that the facility had no evidence the Admelog order had ever been clarified with the nurse practitioner before January 24. Whether anyone actually made that call, and what was said, could not be established from the records that existed.
For a person with Type 1 diabetes, going without prescribed insulin is not a paperwork problem. Blood sugar rises without it. The sliding scale orders in R4's chart directed staff to call a physician if readings exceeded 400 milligrams per deciliter. What his readings were during those two days, and what happened to him clinically, is not stated in the inspection report.
The complaint inspection was conducted October 22, 2025. Inspectors classified the harm level as minimal harm or potential for actual harm, with few residents affected. The director of nursing and the administrator were informed of the findings before inspectors left the building.
R4 had called 911 himself, from the edge of a road, confused, in January. Nine months later, inspectors were still reconstructing what happened from staff interviews because the medical record contained nothing.
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: 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 8, 2026 · Our methodology
WESTPORT REHABILITATION AND NURSING CENTER in RICHMOND, VA was cited for violations during a health inspection on October 22, 2025.
A unit manager had stepped in to cover.
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.