Resident 104 requires complete assistance for all daily activities due to paralysis from quadriplegia, spinal stenosis, and effects from a transient ischemic attack. The resident scores a perfect 15 out of 15 on cognitive assessments, meaning they are fully aware of their circumstances and care needs.
Federal inspectors found gaps in documented care spanning October through December 2025. The resident's care plan specifically requires assistance from one person for daily activities, is completely dependent on staff for feeding at meals, and needs two people to help with bed mobility.
Staff failed to document turning and repositioning care on day shifts November 28 and December 3, and on night shifts October 29, October 31, November 25, November 30, and December 11.
Incontinence care documentation was missing on day shifts November 28, December 3, December 4, and December 14. Night shifts lacked documentation on October 26, October 29, October 31, November 25, November 30, and December 12.
Feeding documentation disappeared on day shifts for breakfast and lunch on November 28 and December 3, and for night shift suppers on October 29, October 31, November 25, November 30, and December 12.
The resident requires an indwelling urinary catheter due to obstructive neurogenic bladder and is always incontinent of bowel. The care plan mandates catheter care every shift and monitoring for signs of infection such as dark or cloudy urine or blockage.
When inspectors interviewed a certified nursing assistant on December 15, the staff member explained that all care gets documented in the facility's electronic system on ADL forms. Asked what happens when documentation is missing, the assistant was direct: "No, there would not be any evidence of the care. They are to document all care given in the ADL form."
The facility's own nursing policy references standard textbooks for long-term care, including specific requirements to "record and document your observations" when turning and repositioning residents.
Administrators, the director of nursing, and assistant directors of nursing were notified of the inspection findings on December 17. The facility provided no additional information before inspectors completed their review.
The violations represent a failure to provide basic activities of daily living assistance to a resident who cannot perform any self-care. For someone with quadriplegia, regular turning prevents pressure sores that can become life-threatening infections. Proper incontinence care prevents skin breakdown and urinary tract infections. Feeding assistance ensures adequate nutrition for someone who cannot feed themselves.
The resident's comprehensive care plan, dated August 1, 2024, acknowledges their complete dependence on staff due to weakness, quadriplegia, and hand contractures. The plan specifically calls for assistance with all activities of daily living and identifies the resident as dependent for bathing, transfers, dressing, toileting, and eating.
Missing documentation across multiple shifts and different types of care suggests systemic problems with either providing care or recording it. The nursing assistant's acknowledgment that undocumented care leaves no evidence it occurred raises questions about whether the paralyzed resident received necessary assistance during the documented gaps.
The inspection was conducted in response to a complaint, indicating someone reported concerns about care quality at the facility. Federal regulators classified the violations as causing minimal harm or potential for actual harm, though for a completely dependent quadriplegic resident, gaps in basic care can quickly escalate to serious medical complications.
Westport Rehabilitation operates at 7300 Forest Avenue in Richmond. The facility houses residents requiring both short-term rehabilitation and long-term nursing care. This resident's case illustrates the vulnerability of those who depend entirely on staff for survival and basic human dignity.
The resident remains cognitively intact, fully aware of their care needs and any lapses in assistance. For someone who cannot move, speak up easily, or care for themselves, consistent documentation serves as the only proof that essential care was provided during each shift.
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
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