Portsmouth Health And Rehab
PORTSMOUTH HEALTH AND REHAB in PORTSMOUTH, VA — inspection on September 19, 2025.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of R119s admission Record located under the Profile tab of the EMR, indicated the resident was admitted to the facility on [DATE].Review of R119's death in the facility MDS, located under the MDS tab of the EMR and with an ARD of 12/17/24, revealed the resident passed away on this date.Review of a document for R119 titled Record of Death, located under the Misc (Miscellaneous) tab of the EMR and dated 12/17/24, indicated the resident passed away at 5:20 PM and his body was released to the funeral home at 10:11 PM.
During an interview on 09/17/2025 at 2:48 PM, the Central Supply Manager (CSM) stated she was assigned to R106's room to ensure everything was in place. CSM stated she did not remember if the body of R119 was left in his room but stated it was the facility policy to offer the living resident another room.
During an interview on 09/17/25 at 5:53 PM, the Administrator stated the process for a resident who has passed away was to offer the roommate outside diversional activities or to offer another room.During an interview on 09/18/25 at 8:37 AM, Licensed Practical Nurse (LPN) 9 who was an agency staff member stated when a resident has passed away, staff were to pull the curtain and offer any roommate another room.
During an interview on 09/18/2025 at 3:58 PM, the MDS Coordinator (MDSC) stated she was the staff member who pronounced the death of R119 only and was not the staff member who spoke with R106 about moving to another room.
The MDSC stated it was the facility's policy to offer the resident another room after a death of their roommate.
During an interview on 09/18/2025 at 4:02 PM R106 stated he was not offered another room after R119 passed away.
During an interview on 09/18/25 at 5:15 PM, the Administrator stated, We do not have a specific policy for dignity.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Portsmouth Health and Rehab
900 London Boulevard Portsmouth, VA 23704
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 09/19/25 at 9:03 AM, LPN1 stated she saw LPN14 with a water pitcher in her hand at the medication cart in the hallway and R53 was screaming in front of her in his wheelchair screaming at her with a wet floor sign in his hand. LPN1 also stated she went to R53's room with him, he told her about the incident, and she stayed with him until he didn't want to be disturbed. LPN1 indicated LPN14 wrote a statement and then left the facility and has not returned to the facility.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Portsmouth Health and Rehab
900 London Boulevard Portsmouth, VA 23704
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 09/17/25 at 5:22 PM, the Administrator confirmed she was not notified of the verbal abuse to R53 when it was observed by LPN1 and reported to the on-call manager on 03/23/25 around 11:00 PM.
The Administrator confirmed she did not report it within two hours to the state survey agency (SSA), and did not submit the initial and 5-day follow-up report to the SSA within the required timeframes.
The Administrator stated LPN1 left a concern note on 03/25/25 regarding the incident so she submitted the initial report to the SSA on 03/25/25, initiated the investigation, asked LPN14 to write a statement, substantiated abuse in the 5-day report on 04/03/25, and then training was conducted with all the staff on abuse, neglect, and reporting abuse.
The Administrator also indicated LPN14 was suspended during the investigation and terminated on 03/25/25.
During an interview on 09/18/25 at 5:33 PM, LPN14 stated R53 tried to attack her in the hallway with a wet floor sign and cursed at her at the medication cart after she administered his medications to him on 03/23/25. LPN14 confirmed she picked up the water pitcher off the medication cart and said she would crack him in the head if he didn't get away from her. LPN14 also stated she wrote a statement at the request of LPN1 and left for the evening, verbally quit, and only returned to the facility to provide another statement to the Administrator on 03/25/25.
During an interview on 09/19/25 at 9:03 AM, LPN1 stated she saw LPN14 with a water pitcher in her hand at the medication cart in the hallway and R53 was screaming in front of her in his wheelchair with a wet floor sign in his hand. LPN1 indicated she reported abuse to the on-call manager but could not remember the name of the manager after R53 explained what occurred around 11:00 PM on 03/23/25. LPN1 also indicated the on-call manager instructed her to write a statement and to get one from LPN14. LPN1 also stated she thought she reported timely.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Portsmouth Health and Rehab
900 London Boulevard Portsmouth, VA 23704
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 09/18/25 at 11:22 AM, the Director of Nursing (DON) 1 stated discontinued narcotic medications should be pulled from the medication carts along with a completed narcotic sheet and then given to her to destroy with another nurse. DON1 also stated it was not in nursing scope of practice to administer medications without an order, and nurses should verify or obtain an order prior to administering any medications to residents.
During an interview on 09/18/25 at 1:59 PM, the Administrator stated DON2 initiated the investigation of the incident and facilitated the destruction of the discontinued narcotic medications.
During an interview on 09/18/25 at 11:31 AM, the Physician Assistant (PA) stated she was not on call on 04/25/25 but expected the nurses to obtain an order from the on-call providers prior to administering any medications.
The PA stated R13 had received lorazepam in the past for agitation and there were no negative outcomes because of receiving the medication.
During an interview on 09/18/25 at 11:50 AM, DON2 confirmed her investigation was substantiated when RN2 was practicing out of scope when she administered the discontinued lorazepam to R13 without a new order while he experienced a seizure on 04/25/25. DON2 stated she terminated LPN5 on 05/01/25 and RN2 admitted she administered the medication without an order because it was an emergency.
During an interview on 09/18/25 at 1:11 PM, the Medical Director stated he expected the nurses to obtain an order for medications and not administer discontinued medications for it was in their scope of their practice.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Portsmouth Health and Rehab
900 London Boulevard Portsmouth, VA 23704
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on [DATE] at 10:26 AM, Physician Assistant (PA) stated she was at the facility on [DATE] when R109 was found unresponsive in her room by CNA1 and LPN1.
The PA stated she expected staff to initiate CPR until they determine their code status if found unresponsive. PA confirmed the staff did not honor R109's wishes of DNR when they began chest compressions on the resident. PA indicated she was concerned that the facility did not have the code status of the residents when the power went out in the building and the EMR could not be accessed.
During an interview on [DATE] at 4:57 PM, the SSD confirmed when she began employment in [DATE], she performed an audit of the resident's code status, created a code status binder which included a copy of the resident's DNR order, CPR and Advance Directive policy and procedure, daily census for each unit, and then placed the binder at the two nurses' stations in the building for staff to use during a power outage.
During an interview on [DATE] at 1:01 PM, the Medical Director stated he expected the nursing staff to follow the resident's code status orders and a DNR means no CPR was provided and the code status should be verified in the computer first.
The Medical Director also stated R109 was sent to the hospital and returned unharmed.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Portsmouth Health and Rehab
900 London Boulevard Portsmouth, VA 23704
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 09/18/25 at 10:36 AM, the Director of Nursing (DON) stated her expectation was if a resident was on routine pain medication and it was not administered, the nurse should have then documented the reason in the EMR.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Portsmouth Health and Rehab
900 London Boulevard Portsmouth, VA 23704
SUMMARY STATEMENT OF DEFICIENCIES
Federal health inspectors cited PORTSMOUTH HEALTH AND REHAB in PORTSMOUTH, VA for a deficiency under regulatory tag F-F0755 during a complaint investigation conducted on 2025-09-19.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 7 deficiencies cited during this inspection of PORTSMOUTH HEALTH AND REHAB.
Correction Status: Deficient, Provider has no plan of correction.