Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Care Of Portsmouth during CMS and state inspections, most recent first.
Failure to honor resident meal choices affected multiple residents with varying cognitive status and diagnoses such as DM, malnutrition, CKD, dysphagia, depression, anxiety, obesity, anemia, and ESRD. Resident Council minutes and resident interviews showed that alternate meal orders were often not followed, ordered items were missing or replaced without notice, and kitchen staff sometimes ran out of menu items during service. Observations confirmed that tray cards were not updated with alternate orders, residents received regular meals instead of requested items, and substitutions were made at the tray line.
Failure to protect residents from resident-to-resident abuse. A resident with intact cognition was threatened and verbally abused by another resident, and the resident told staff he felt uncomfortable and unsafe. In separate incidents, one resident was struck in the hallway by another resident during a wheelchair escort, and another resident was hit with a bed remote by a roommate after the roommate became agitated. The facility’s investigation substantiated resident-to-resident contact in both of those incidents, and the abuse policy was not effectively implemented to protect the residents involved.
Failure to Timely Report Resident-to-Resident Abuse Allegations: The facility did not ensure allegations of resident-to-resident abuse were reported to the SA within required time frames. One resident with intact cognition was documented as being struck by a roommate, and another resident with intact cognition was threatened and yelled at by a peer, leaving the resident uncomfortable and fearful. An LPN and the Administrator gave conflicting accounts of reporting, and the Administrator stated she was not aware of the regulatory requirement for immediate reporting of abuse or serious bodily injury allegations.
Menu Not Followed for Mechanical Soft and Puree Diets: A cook did not follow the posted lunch menu for residents on mechanical soft and puree diets. Instead of the ordered texture-specific items, he served mashed potatoes in place of buttered noodles and cream of rice, and no pureed bread was provided. The cook stated he did not look at the menu, and the DM and DRM noted he needed more training on following menus.
An LPN touched tablets with a bare finger during medication preparation for two residents, then returned the tablets to the bottles. Staff also entered a resident’s room under neutropenic and contact precautions wearing only a mask on multiple occasions instead of the PPE indicated on the door signage and by the DON.
Failure to provide written Advance Directive information for a resident with COPD, CHF, and moderately impaired cognition. Staff said they ask about Advance Directives and code status on admission, but do not give residents written information. The resident was Full Code, and the facility policy stated that Advance Directive information, including living wills and medical POA, is provided on admission.
Failure to Thoroughly Investigate Resident-to-Resident Abuse Allegation: A resident with a history of physical and verbal behaviors threatened another cognitively intact resident, yelling and cursing at him and making physical threats after accusing him of urinating on the toilet seat. The other resident said he felt uncomfortable, but the facility’s investigation was incomplete: the incident date was not identified in the follow-up, only the two residents and one LPN were interviewed, other residents were not asked about the specific event, and the LPN was not interviewed or asked for a statement. The facility policy required an immediate investigation.
Missing transfer and bed hold notice: A resident with TIA and moderately impaired cognition was sent to the hospital after becoming unable to speak and having weak bilateral hand grips. The EMR did not show documentation that the written transfer notice and bed hold policy were provided to the resident and/or RP, and staff gave inconsistent descriptions of how the forms were handled and whether the RP received the information.
MDS coding was inaccurate for two residents. One resident with multiple admission diagnoses had two pressure ulcers documented in the chart, including a stage IV sacral ulcer and an unstageable heel ulcer, but the MDS coded only one. Another resident with COPD had physician-ordered continuous oxygen and a note documenting oxygen via nasal cannula, but the quarterly MDS did not code oxygen therapy. The MDSC said she relied on the MAR and her observation of the room, while the DON stated MDS assessments should be completed accurately.
PASARR Level I screenings were inaccurate or missing for three residents. Two residents had diagnoses of IDD or mental illness, but their DMAS-95 screenings did not identify those conditions, and another resident with bipolar disorder had no PASARR documentation prior to or within 30 days of admission. The SSD said she was not responsible for completing PASARRs, the DON said they should be completed accurately, and the RVPO could not find a PASARR for the resident.
Care plans for three residents did not include targeted behaviors related to anxiety meds. One resident with MS and CHF had a PRN lorazepam order for terminal agitation, restlessness, anxiety, insomnia, or hallucinations, but the care plan only said to monitor mood and response. Two other residents with anxiety, bipolar disorder, or depression had psychotropic meds ordered, yet their care plans also lacked specific behaviors to monitor, and the DON stated care plans should reflect the care being received, including known behaviors.
A resident’s smoking care plan was not updated after his smoking status changed. The resident, who had dementia, psychosis, glaucoma, schizoaffective disorder, B-cell lymphoma, and hospice involvement, was observed smoking independently and staff confirmed he could hold his own cigarette and stored his smoking materials in a locked locker. However, the care plan still listed interventions such as gloves, a cigarette holder, intermittent supervision, designated-area smoking, and 1:1 supervision, which were inconsistent with his current abilities; the DON and MDSC acknowledged the plan should have been revised when his condition changed.
A resident with a BIMS score of 15/15 and no cognitive impairment was given crushed meds even though the resident wanted to take them whole. Staff relied on a broad crush order and crushed all meds without checking which ones could or could not be crushed; the NP and DON stated the resident’s meds should not have been crushed, and Abilify specifically should be swallowed whole.
Failure to administer oxygen per physician orders for two residents: one resident with COPD and CHF was ordered O2 at 3 L/min NC continuously but was observed multiple times with the concentrator set at 2 L/min, and an RN later confirmed and corrected the setting. Another resident with COPD had an order for O2 at 2 L/min continuously, but the MAR had no documentation of oxygen administration and the resident was observed with the concentrator set at 3 L/min; an LPN confirmed the incorrect setting and lack of documentation.
Failure to Follow Dialysis Weight Orders: A resident with ESRD receiving hemodialysis had physician orders for pre- and post-dialysis weights, but the record showed weights were documented only on limited occasions and not consistently as ordered. The resident was not care planned for dialysis, and an LPN stated residents should be weighed before leaving and after returning from dialysis, with refusals documented rather than unavailable entries; the DON stated staff were expected to follow physician orders, and the facility policy required pre- and post-treatment weights.
Failure to Honor Resident Meal Choices
Penalty
Summary
The facility failed to honor resident food choices for 11 of 98 residents, including residents with intact cognition and residents with moderately impaired cognition. The residents involved included R5, R15, R94, R93, R103, R120, R84, R63, R49, R8, and R22. Several of these residents had diagnoses including diabetes, malnutrition, obesity, cirrhosis of the liver, chronic kidney disease, dysphagia, depression, anxiety, anemia, and end stage renal disease. MDS assessments showed BIMS scores ranging from 6 to 15, indicating that some residents had intact cognition while others had moderate impairment. Resident Council minutes documented that residents put in alternate lunch and dinner orders, but dietary sent what they wanted instead. The minutes also noted that alternate dietary sheets were placed in mailboxes and that the process was no longer verbal. During a resident group interview, multiple residents stated they did not receive the foods they ordered on the alternate order sheet at times. Residents reported that even when forms were submitted on time, they still did not receive the requested items, that the kitchen often ran out of menu items, and that substitutions were made without notifying them. Residents also stated these concerns had been raised in Resident Council meetings but had not improved. During interviews, the Dietary Regional Manager stated the department had switched to alternate order sheets after the concern was raised, but there had been no formal education for staff or residents and no documented follow-up to determine whether the change improved the issue. During meal service observation, the alternate order forms were on the kitchen counter near the tray line, but tray cards were not updated and still listed the regular menu meal for all residents. Residents who had ordered specific items did not receive those items on their trays, including missing vegetables, side salads, and a chicken pot pie. Staff also ran out of Capri mixed vegetables during service and substituted green peas for residents who had ordered the regular meal. The Dietary Manager stated that when substitutions were made before meal service, the menu would be updated, but mid-service changes were not necessarily announced to residents.
Failure to Protect Residents from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse policy and protect residents from resident-to-resident encounters involving three sampled residents. The report states that R123, R112, and R111 were involved in separate incidents with other residents, and that the facility did not adequately prevent or respond to the encounters as described in the findings. For R123, the record showed a BIMS score of 15 out of 15 and no cognitive impairment. On 05/24/25, R122 was observed cursing and yelling at R123 in his room and threatening him with physical harm while accusing him of urinating on the toilet seat. Nursing notes documented that R122 had to be redirected multiple times before walking away. R123 told staff he was starting to feel uncomfortable because no one should be coming to his door yelling and cursing at him. During interview, an LPN stated R122 repeatedly threatened to put his hands on R123 and said he knew people who would take care of him, and that R123 was absolutely scared and said he did not feel safe. For R112, the record showed intact cognition and a history of Charcot's joint of the right ankle and foot and end stage renal disease. The incident report documented that while R112 was being wheeled through the hallway after a dialysis appointment, R26 was in the hallway and would not move when asked. R112 alleged that R26 kicked her leg and made contact with his injured leg and external fixator. The facility’s follow-up report stated that after interviews it was established that resident-to-resident contact occurred, and the Administrator stated the incident was substantiated through investigation. For R111, the record showed diagnoses including PTSD, depression, and muscle weakness, with intact cognition on admission and later moderately impaired cognition. A nursing note documented that the roommate grabbed R111’s bed remote and hit him on the left arm and left leg several times, and the incident report stated that R121 used the bed remote to hit R111 after becoming agitated. The follow-up report also stated that resident-to-resident contact occurred and that the incident was substantiated through investigation.
Failure to Timely Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to ensure allegations of resident-to-resident abuse were reported to the State Agency within the required time frames for four residents reviewed for abuse. One resident, who had diagnoses including PTSD, depression, and muscle weakness and had intact cognition on admission MDS, was documented by an LPN as being struck on the left arm and left leg several times by a roommate who grabbed the resident’s bed remote while the resident was awake in bed watching TV. The resident was immediately removed from the room, and the allegation was later reported to the State Agency more than seven hours after it was first documented. Another incident involved two residents with intact cognition. One resident had a care plan for a history of physical and verbal behaviors, with interventions including psychiatric evaluation, monitoring for behavior changes, and care by two staff members. Nursing notes documented that this resident cursed at and threatened the other resident with physical harm, yelled at the resident’s room, and made statements about the resident being from Russia. The other resident stated feeling uncomfortable and fearful because no one should be coming to the door yelling and cursing. The facility incident report showed the allegation was not reported to the State Agency until two days later. During interviews, an LPN stated she reported the first incident to the on-call physician and administration right away, while the Administrator stated she believed allegations causing severe bodily injury had to be reported within two hours and other allegations within 24 hours, but she was not aware of the regulatory requirement and facility policy requiring immediate reporting of allegations of abuse or events causing serious bodily injury. The Administrator could not explain why the second allegation was not reported until two days later and stated it should have been reported immediately to a supervisor. The facility policy required all allegations of abuse, neglect, involuntary seclusion, injuries of unknown source, and misappropriation to be reported immediately to the Administrator, DON, and applicable State Agency, and abuse or serious bodily injury allegations to be reported to the State Agency immediately, but not later than two hours after the allegation was made.
Menu Not Followed for Mechanical Soft and Puree Diets
Penalty
Summary
The facility failed to follow the menu for mechanical soft and puree diets for 14 residents, including five residents on puree diets and nine residents on mechanical soft diets, out of a census of 98. Review of the facility’s diet guide sheet for lunch showed the regular menu was herb roasted chicken, yellow rice, Capri mixed vegetables, and a dinner roll, with specified alternatives for mechanical soft and puree textures. During lunch service in the kitchen, the Dietary Regional Manager asked the cook what was being served instead of rice for the mechanical soft diet, and he responded mashed potatoes; the DRM stated it should have been buttered noodles. The cook also served mashed potatoes instead of cream of rice for the puree diet, and no pureed bread was available on the tray line or served to residents on the puree diet. During interview, the cook stated he served mashed potatoes instead of noodles for the mechanical soft diet and instead of cream of rice for the puree diet, and he said there was no reason he used mashed potatoes other than, “I just know they can eat it.” He confirmed he had not prepared or served pureed bread and stated he had forgotten. He also stated he did not look at the menu to determine what to serve for mechanical soft and puree diets. The Dietary Manager stated she did not think he looked at the menu to determine the correct foods to serve, and the DRM stated he needed more training on following menus. The DM stated she had recently done an in-service training on following menus, but the cook had not attended.
Infection Control Failures During Medication Handling and Room Entry
Penalty
Summary
The facility failed to follow infection control guidelines during medication administration when an LPN touched tablets with her bare finger before placing them back into the medication bottle. During observation, the LPN prepared Aspirin 81 mg for one resident and Tylenol 325 mg for another resident by pouring tablets into the bottle lid, then using her bare index finger to stop extra tablets from entering the medication cup and returning those tablets to the bottle. The LPN later stated she did not realize she had put her finger on the pills and said she should have worn gloves if she was going to touch them. The DON stated the nurse should never touch pills with bare hands and should have worn gloves if touching the pills. The facility also failed to follow transmission-based precautions for a resident with neutropenic precautions. The resident had a diagnosis of malignant breast cancer and a physician order for neutropenic precautions at all times, with the care plan identifying neutropenic precautions and monitoring for compliance. During observation, signage outside the room directed staff to perform hand hygiene and don a gown, gloves, and mask before entering, but a CNA entered the room to deliver and set up the lunch tray wearing only a mask. The CNA stated she only wore a mask because she was just serving food and was not coming in close contact with the resident. The same resident was observed again when another CNA entered the room wearing only a mask to deliver and set up the dinner tray. The CNA stated he should have worn a gown and gloves in addition to the mask before entering and said he had forgotten. The DON stated that for neutropenic precautions, staff should clean their hands and apply gloves, mask, and gown prior to entering the room, no matter the situation, and that PPE should be donned for every room entry.
Failure to Provide Written Advance Directive Information
Penalty
Summary
The facility failed to provide written information on how to formulate an Advance Directive for one of five residents reviewed for Advance Directives, Resident 30. R30 was admitted with diagnoses including COPD and CHF and was documented as Full Code. Her admission MDS, with an ARD of 01/29/26, showed a BIMS score of 11 out of 15, indicating moderately impaired cognition. During an interview on 02/26/26, R30 stated that if her heart stopped or she stopped breathing, she wanted everything done for her. During interviews on 02/27/26, the Social Services Director stated that a path meeting occurs within three days of admission and that the Advance Directive and code status are reviewed with the resident and/or family member at the bedside. The Registered Nurse stated that residents are asked whether they have an Advance Directive and what code status they would like, but residents are not given any information on Advance Directives. The Admissions Director stated that the facility asks whether the resident has an Advance Directive when admitted, but does not give them anything about it. Review of R30's admission packet showed a written summary of the facility Advance Directive policy and an option indicating whether the resident had executed an Advance Directive. The facility policy titled, Advanced Care Planning Meeting Protocol, stated that information such as living wills, medical power of attorney, the resident's right to form an Advance Directive, and the right to refuse medical/surgical treatment is provided to the resident and family by the facility on admission.
Failure to Thoroughly Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse policy and thoroughly investigate an allegation of resident-to-resident abuse involving two residents. One resident had a quarterly MDS with a BIMS score of 15 out of 15, indicating no cognitive impairment, and was care planned for a history of physical and verbal behaviors with interventions including psychiatric evaluation as needed, monitoring for behavior changes, and care by two staff members. The other resident also had a BIMS score of 15 out of 15 on both the 5-day and quarterly MDS assessments, indicating no cognitive impairment, and had diagnoses including cerebral infarction and muscle weakness. A nurse documented that one resident was observed cursing and yelling at the other resident, threatening physical harm, and repeatedly telling him he was from Russia; staff redirected the resident multiple times before he walked away. The other resident stated he felt uncomfortable because no one should be coming to his door yelling and cursing at him. The follow-up investigation did not identify the date of the incident, and only the two residents and one LPN were interviewed. Other residents were asked general mistreatment questions but were not asked about the incident or their observations and interactions with the resident involved. The LPN stated she did not report the incident to a supervisor that night because there was nobody to report to on the 3-11 shift, and she was not interviewed about what happened or asked to write a statement. The Administrator stated staff working on the unit at the time of an incident and other residents would normally be interviewed, but was unsure why no other staff besides the LPN was interviewed. The facility policy stated staff must immediately begin an investigation.
Missing transfer and bed hold notice
Penalty
Summary
The facility failed to ensure that a written transfer notice containing all required information and the bed hold notice were provided for one resident, R74, and/or the resident’s responsible party when the resident was transferred to the hospital. R74’s record showed a readmission diagnosis of transient cerebral ischemic attack (TIA), and the quarterly MDS documented a BIMS score of 12 out of 15, indicating moderately impaired cognition. A nursing progress note dated 11/09/25 at 7:02 PM stated the resident was alert but unable to speak when his name was called, with weak bilateral hand grips, normal vital signs and blood sugar, and the nurse practitioner was notified that the resident would be sent out for further evaluation. Review of the electronic medical record did not show documentation that the facility provided the written transfer and bed hold policy to the resident and RP when R74 was transferred to the hospital. During interviews, the SSD stated nurses complete the transfer notice and bed hold policy forms, but she was not aware of what happens after that. RN2 stated the forms are placed in an envelope given to the EMTs and taken to the hospital with the resident, and RN2 was not sure how the transfer notice and bed hold policy was provided to the RP. The RVPO stated the Social Worker is to call the resident’s representative and/or the resident after transfer to review the information. The facility policy titled Discharge Planning Policy stated transfers and discharges will meet regulatory requirements and that the transfer or discharge will be documented in the resident’s medical record and necessary information communicated to the receiving healthcare institution or provider.
MDS Did Not Accurately Reflect Pressure Ulcers and Oxygen Use
Penalty
Summary
The facility failed to ensure the MDS accurately reflected the status of two sampled residents. For one resident admitted with diagnoses including stroke, malnutrition, gout, muscle weakness, seizures, and diabetes, the admission MDS with an ARD of 01/29/26 documented only one unstageable pressure ulcer. However, the resident’s care plan identified pressure ulcers to the sacrum and left heel, the admission/readmission observation noted pressure ulcers to both areas on admission, and wound documentation showed a stage IV pressure ulcer to the sacrum and an unstageable pressure ulcer to the left heel, both present on admission and still present on 01/31/26. During interviews, the MDS Coordinator stated she was unsure why only one pressure ulcer was coded, and the IP stated both pressure ulcers should have been reflected on the MDS. For another resident admitted with COPD, the quarterly MDS with an ARD of 01/26/26 did not code oxygen therapy. The resident’s care plan stated the resident required oxygen due to COPD, and physician orders directed oxygen at 2 LPM via nasal cannula continuously. A nurse practitioner note documented the resident had oxygen in place via nasal cannula at 3 L with oxygen saturation of 98%. During interview, the MDS Coordinator stated she did not indicate oxygen use on the MDS because she saw no MAR documentation and did not observe oxygen equipment in the room, and she had no documentation of that observation. The DON stated she expected MDS assessments to be completed accurately.
Inaccurate or Missing PASARR Level I Screenings
Penalty
Summary
PASARR Level I screening was not completed accurately for two residents. One resident was admitted with a diagnosis of unspecified intellectual disabilities, but the DMAS-95 Level I screening dated 12/20/24 did not indicate intellectual developmental disability. Another resident was admitted with diagnoses including anxiety disorder and schizoaffective disorder, bipolar type, but the DMAS-95 Level I screening dated 04/13/24 did not indicate mental illness. The report states the facility failed to ensure accurate PASARR Level I assessments were completed for these residents. A third resident was admitted with a diagnosis of bipolar disorder and had an admission MDS showing a BIMS score of 11 out of 15, indicating moderately impaired cognition. Review of the resident’s EMR showed no documentation of a PASARR being completed prior to or within 30 days of admission. During interviews, the SSD stated she was not responsible for completing PASARR Level I screenings and said the Administrator completed them, while the DON stated she expected PASARR assessments to be completed accurately. The RVPO stated she could not find a PASARR for the resident and that one should have been completed.
Care plans lacked targeted behaviors for anxiety medication
Penalty
Summary
The facility failed to develop care plans for three residents that included targeted behaviors for the use of anxiety medication. For one resident with multiple sclerosis and CHF who was readmitted to the facility and had moderately impaired cognition, the care plan identified anxiety medication for terminal agitation, restlessness, anxiety, insomnia, or hallucinations and included only monitoring the resident’s mood and response to medication. The physician order was for lorazepam concentrate every four hours as needed for those symptoms for 14 days, but the care plan did not identify the specific behaviors staff were to observe. During interview, the MDSC stated that each resident is different and that staff could look at how the resident acts when she has anxiety and add those behaviors to the care plan. For another resident with generalized anxiety disorder and bipolar disorder who had moderately impaired cognition and was receiving antipsychotic and antianxiety medication, the care plan stated the resident receives antianxiety medication related to anxiety/bipolar and included monitoring the resident’s mood and response to medication. The physician orders included Abilify, bupropion, buspirone, and Xanax for bipolar disorder and anxiety, but the care plan did not include targeted behaviors. For a third resident with adjustment disorder with mixed anxiety and depressed mood who was cognitively intact and receiving antidepressant and antianxiety medication, the care plan identified antidepressant medication due to depression and anxiety and included monitoring for adverse side effects and behaviors per psych orders, but it did not specify the resident’s known behaviors. The DON stated that the resident’s care plan should reflect the care they are receiving, including the behaviors the resident is known to exhibit.
Outdated Smoking Care Plan Not Updated for Resident Who Regained Independent Smoking Ability
Penalty
Summary
The facility failed to ensure timely review and revision of the care plan for one resident, R42, whose smoking status had changed. R42 was originally admitted with diagnoses including B-cell lymphoma with intrapelvic lymph nodes, unspecified psychosis, glaucoma, dementia, and schizoaffective disorder. The quarterly MDS dated 02/10/26 documented a BIMS score of 9 out of 15, indicating moderately impaired cognition, and the EMR also showed the resident had been admitted to hospice care as of 5/16/25 with a significant change MDS completed. During observation on 02/25/26, R42 was seen returning from the smoking area without burns or safety concerns, and CNA5 stated the resident was an independent smoker who could hold his own cigarette and kept smoking materials in a locker with a key. However, the Smoking Care Plan initiated on 09/23/25 still identified the resident as an unsupervised smoker with interventions including intermittent supervision, smoking gloves, designated-area smoking, use of a cigarette holder, and 1:1 supervision, which were inconsistent with his current abilities. R42 later confirmed he did not wear an apron or gloves and did not need help holding smoking materials, and he was observed smoking unassisted. The DON acknowledged the resident had regained the ability to smoke independently and stated the care plan should have been updated, while the MDSC acknowledged outdated interventions should not remain on the care plan and that revisions are required when resident status changes.
Crushed medications given without clinical indication
Penalty
Summary
The nursing facility failed to ensure staff maintained professional standards of practice when Resident 122 was given crushed medications without a clinical indication for crushing all medications. The resident’s quarterly MDS showed a BIMS score of 15 out of 15, indicating no cognitive impairment. The care plan documented behavioral symptoms, including that the resident pocketed medications and refused to give them to the nurse. A physician order dated 02/10/25 stated medications may be crushed unless contraindicated, but the record also showed that on 07/21/25 the resident became upset when medications were crushed and threw the medication cup in the trash because the medications had been crushed. The NP documented that nurses had obtained a crushed medication order, but the resident refused to take medications that morning because they were crushed and wanted to take them whole. Later that day, an LPN documented that the resident had a new order to administer Abilify in the morning and that medications no longer had to be crushed. During interviews, the LPN stated staff crushed all medications if the order said to crush and did not double-check which medications could or could not be crushed. The NP and DON stated that R122’s medications should not have been crushed, and the DON said the order should specify only the particular medication that needed to be crushed. A review cited that Abilify should not be crushed, chewed, or divided and should be swallowed whole.
Failure to Administer Oxygen per Physician Orders
Penalty
Summary
The facility failed to administer oxygen in accordance with physician orders for two residents who were receiving oxygen therapy. One resident had diagnoses of COPD and CHF, a BIMS score of 11, and an order for oxygen via nasal cannula continuously at 3 L/min. During multiple observations, the resident was found in bed with the oxygen concentrator set at 2 L/min instead of the ordered 3 L/min. An RN later confirmed the setting was 2 liters, reviewed the EMR, verified the order was for 3 L/min, and then adjusted the concentrator to 3 L/min. A second resident with COPD and moderate cognitive impairment had a physician order for oxygen at 2 L/min via nasal cannula continuously, and the care plan directed staff to administer oxygen per physician orders. Review of the MAR for January and February showed no documentation that oxygen was being administered at 2 L/min continuously. During observations, the resident was found with the nasal cannula in place and the oxygen concentrator set at 3 L/min, with a sign on the concentrator indicating to keep oxygen at 2 L/min. An LPN confirmed the setting was 3 L/min, was unsure if it was correct, and stated she did not remember checking the concentrator or documenting oxygen administration on the MAR.
Failure to Follow Dialysis Weight Orders
Penalty
Summary
The facility failed to ensure that staff followed physician orders for a resident with chronic kidney disease, end stage renal disease, and dependence on renal dialysis. The resident was receiving hemodialysis three times per week, and the physician orders included pre-dialysis and post-dialysis weights on those treatment days. Review of the resident’s record showed that weights were only documented on limited dates in February, with no consistent pre- and post-dialysis weights recorded as ordered. The resident’s care plan did not include dialysis treatment. During interview, an LPN stated residents receiving dialysis should be weighed before leaving the facility and again upon return, and that there should be either a documented weight or a documented refusal, not an unavailable entry. The LPN also stated the pre- and post-dialysis weights were important for estimating fluid removed during dialysis. The DON stated she expected staff to absolutely follow physician orders. The facility policy for hemodialysis care required communication before and after each treatment and documentation of pre-treatment and post-treatment weights.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Portsmouth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Portside Health & Rehab Center | 2 mi | ★★★★★ | 0 | 0 |
| Portsmouth Health And Rehab | 2.3 mi | ★★★★★ | 7 | 1 |
| Deep Creek Health & Rehabilitation | 3.3 mi | ★★★★★ | 13 | 0 |
| Harbor's Edge | 3.6 mi | ★★★★★ | 2 | 0 |
| Signature Healthcare Of Norfolk | 3.7 mi | ★★★★★ | 0 | 0 |
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