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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
495149 09/19/2025
Portsmouth Health and Rehab 900 London Boulevard Portsmouth, VA 23704
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.
495149 09/19/2025
Portsmouth Health and Rehab 900 London Boulevard Portsmouth, VA 23704
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.
495149 09/19/2025
Portsmouth Health and Rehab 900 London Boulevard Portsmouth, VA 23704
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.
495149 09/19/2025
Portsmouth Health and Rehab 900 London Boulevard Portsmouth, VA 23704
During an interview on [DATE] at 1:01 PM, the Medical Director stated he expected the nursing staff to follow
be verified in the computer first.
The Medical Director also stated R109 was sent to the hospital and returned unharmed.
495149 09/19/2025
Portsmouth Health and Rehab 900 London Boulevard Portsmouth, VA 23704
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.
495149 09/19/2025
Portsmouth Health and Rehab 900 London Boulevard Portsmouth, VA 23704
Review of R13's Physician's Orders, dated [DATE], located in the EMR under the Orders tab, revealed an order for lorazepam injection solution 2 milligrams (MG)/Milliliters (ML) inject 0.5 ML intramuscularly one time only for agitation/combative for one day.
Review of R13's Alert Note, dated [DATE], located in the EMR under the Prog Notes tab, revealed This nurse called to pt's [patient's] bedside for c/o [complaints of] distress by CNA. Pt. was found in bed, actively seizing . Pt. seized for 4 minutes then stopped for 10 sec [seconds] and seized again for 5 minutes. 0.5 cc [cubic centimeters] IM [intramuscular] Ativan given in right deltoid.
Review of the facility's internal investigation, dated [DATE], revealed R13 exhibited seizure like activity on [DATE]. LPN5 provided supportive care and called for assistance from Registered Nurse (RN) 2. LPN5 contacted 911, and RN2 noted R13 had Ativan IM in the narcotic drawer, however, the medication had been discontinued and there was not an active order. LPN5 brought the medication to R13's room and RN2 administered the IM Ativan to stop the seizure.
Actions taken included suspending LPN5 during the investigation on [DATE] then terminating him on [DATE]. RN2 was removed from the schedule and agency was informed that she was a do not return to the facility on [DATE].
All nursing staff were re-educated on following physician's orders, medication administration, and the narcotic destruction process for discontinued medications on [DATE] by Director of Nursing (DON) 2. DON2 audited the medication cart narcotic boxes and facilitated the destruction of the discontinued narcotics.
During an interview on [DATE] 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.
During an interview on [DATE] at 1:59 PM, the Administrator stated DON2 initiated the investigation of the incident and facilitated the destruction of the discontinued narcotic medications on [DATE].
The Administrator stated DON2 facilitated destroying the controlled medications with the unit managers during the investigation.
During an interview on [DATE] at 11:50 AM, DON2 stated she had worked for the facility a couple of weeks when she completed the investigation and determined RN2 administered R13's discontinued lorazepam which should have been pulled from the medication cart and given to her for destruction. DON2 also stated she asked the unit managers to remove discontinued and expired controlled medications from the medication carts and began destroying the medications with them after the incident on [DATE].
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.