Portsmouth Health and Rehab: Missed Pain Meds - VA
Federal inspectors documented the lapses in a complaint inspection completed September 19, 2025. The resident, identified in inspection records only as Resident 106, had been prescribed oxycodone hydrochloride, 5 milligrams, every six hours for chronic pain stemming from a motor vehicle accident. His care plan, dated November 2024, listed the injury as the source of intermittent pain and directed staff to medicate him as ordered and follow up on whether it was working.
The medication administration records told a different story.
In December 2024, nurses failed to assess the resident's pain and give him his oxycodone on six separate occasions: December 10 at 6:00 a.m., December 15 at 6:00 a.m., December 23 at midnight, December 26 at both midnight and 6:00 a.m., and December 28 at 6:00 a.m. Then, in the first week of January 2025, it happened three more times: January 4 at 6:00 p.m., January 5 at both 6:00 a.m. and 6:00 p.m., and January 6 at midnight.
Nine missed doses. No documentation in the progress notes for either month explaining the omissions.
The resident was not someone who couldn't speak for himself. His admission assessment, completed in September 2024, showed a perfect score on the Brief Interview for Mental Status, 15 out of 15, meaning he was fully cognitively intact. He was also ambulatory. Whatever happened on those nine occasions, it wasn't that staff couldn't ask him whether he was in pain.
The Director of Nursing, interviewed by inspectors on September 18, 2025, said her expectation was clear: if a routine pain medication wasn't given, the nurse responsible should have documented the reason in the electronic medical record. No such documentation existed for any of the nine missed doses.
That gap matters beyond paperwork. Oxycodone prescribed on a scheduled, around-the-clock basis for chronic pain is meant to maintain a consistent level of relief. Missing a dose at 6:00 a.m. doesn't just mean a few uncomfortable hours until the next scheduled administration. For someone managing pain from a serious injury, gaps in a routine regimen can mean the medication's effect wears off entirely before the next dose arrives, leaving the resident to wait out the pain with no record that anyone noticed or cared.
Inspectors cited the facility for failing to ensure narcotic pain medications were administered as ordered, classifying the harm level as minimal harm or potential for actual harm. The finding covered one resident out of 47 reviewed.
The facility's own pain management policy, dated January 2020, required that residents be assessed for pain upon admission, upon significant change, and whenever a resident experiences uncontrolled pain. The medication administration records show those assessments were skipped alongside the missed doses. There is no record that anyone checked whether Resident 106 was hurting on the mornings and nights when his medication went unrecorded and ungiven.
Portsmouth Health and Rehab sits at 900 London Boulevard. The inspection was triggered by a complaint, not a routine survey cycle, meaning someone flagged a concern before inspectors arrived.
What the records don't show is whether Resident 106 ever told anyone he was in pain on those nights. Whether he pressed a call button. Whether he waited until morning and said nothing. The progress notes for December 2024 and January 2025 are silent on all of it.
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.
Download the official CMS inspection PDF from Medicare.gov
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 23, 2026 · Our methodology
PORTSMOUTH HEALTH AND REHAB in PORTSMOUTH, VA was cited for violations during a health inspection on September 19, 2025.
Federal inspectors documented the lapses in a complaint inspection completed September 19, 2025.
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.