Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Portside Health & Rehab Center during CMS and state inspections, most recent first.
The facility failed to provide accurate assessments for four residents, leading to deficiencies in their care plans. A resident with end-stage renal disease was not coded for dialysis in the MDS, despite having a care plan and physician orders for it. Two residents were incorrectly coded for discharge disposition, with one being discharged home instead of to a hospital, and another transferred to a hospital instead of home. Additionally, a resident was not interviewed for pain assessment, leaving a section of the MDS incomplete. These issues were acknowledged by the MDS coordinator and reported to the facility's administrative staff.
The facility failed to develop baseline care plans for two residents within 48 hours of admission. One resident's care plan did not include PTSD or anticoagulation monitoring, despite relevant diagnoses and prescriptions. Another resident's care plan omitted dialysis and oxygen therapy, and fluid restrictions were not implemented as ordered. Interviews with LPNs confirmed these omissions, and the deficiencies were reported to the facility's administrative staff.
The facility failed to implement comprehensive care plans for residents, leading to deficiencies in monitoring anticoagulant therapy, administering medications, and using prescribed splints. Residents were not monitored for side effects of medications, and care plans lacked necessary components for safety and treatment adherence.
The facility failed to update care plans for four residents, omitting the use of bed rails and an indwelling catheter despite physician orders and observations. This oversight was confirmed by LPNs and acknowledged by administrative staff, indicating a lapse in ensuring care plans reflect current needs and safety measures.
Two residents experienced deficiencies in care due to the facility's failure to administer medications and treatments as ordered. One resident with vascular wounds did not receive benzocaine and telfa pads, causing pain and bleeding. Another resident did not receive blood pressure medications and insulin consistently, with documentation gaps in the MAR. These issues highlight a lack of adherence to physician orders and proper documentation.
A resident with ESRD and severe cognitive impairment did not receive proper monitoring for fluid restriction, as required by their care plan. The facility's MAR showed multiple instances of exceeded fluid limits, and an LPN acknowledged the failure to follow orders, possibly due to agency nurses' unfamiliarity with documentation. The facility's policy on intake verification was not followed, leading to the deficiency.
The facility staff failed to monitor two residents for side effects from their anticoagulant medication, Eliquis. Despite physician orders and standard nursing practices requiring monitoring for bleeding, the medication administration records lacked evidence of such monitoring. Interviews with LPNs confirmed the necessity of this practice, but it was not documented. The facility's administrative staff were informed of these deficiencies.
The facility failed to maintain sanitary conditions in the kitchen and nourishment room. Dust and rust were found on kitchen fans, and expired nutritional supplements were discovered in the nourishment room. The dietary manager and maintenance director had unclear responsibilities for fan cleaning, and the central supply staff acknowledged the expired supplements should have been discarded.
The facility failed to conduct and document bed inspections for four residents before using bed rails, as required by policy. Observations showed residents with bed rails in place, but no evidence of prior safety inspections. The maintenance director could not find inspection records before a facility-wide inspection, and the issue was reported to the administrative staff.
A resident was found with a Breyna inhaler on their bedside table without a physician's order or assessment for self-administration. The clinical record and care plan lacked documentation for self-administration, and staff were unaware of the requirements for bedside medication storage. The facility's administration was informed of the issue.
A resident with end-stage renal disease and other conditions was unable to access their call light, which was found on the floor between beds. The resident was not cognitively impaired and required supervision for daily activities. An LPN confirmed the call light was not within reach, contrary to facility policy, and the issue was reported to administrative staff.
The facility failed to provide written notifications to residents and/or their responsible parties upon hospital transfers for three residents. Despite phone notifications, no written documentation was given, and the facility lacked a policy for such notifications. The administration was informed, but no further documentation was provided.
A facility failed to provide evidence of a bed hold notice for a resident transferred to a hospital. The resident, who was rapidly declining, was transported with necessary documents, but no bed hold notice was documented. Interviews and document reviews confirmed the absence of the required notice, despite facility policy mandating its provision.
A resident with limited ROM in the right hand did not receive the recommended splinting device as per OT evaluation. The care plan and physician's orders lacked directives for splinting, and staff interviews revealed a lack of awareness and documentation of the required treatment. The facility's administrative staff was informed of the issue.
A facility failed to provide appropriate care for a resident with an indwelling catheter. The resident was observed with a catheter bag improperly positioned, and there was no documentation of catheter care in the MAR for several months. The care plan did not address the use of the catheter, and staff interviews confirmed the lack of evidence for catheter care. The issue was brought to the attention of the facility's administration.
A resident was continuously administered oxygen at 2 L/min via nasal cannula without a physician's order, as required by facility policy. Despite documentation of oxygen use in the resident's progress notes and during a follow-up visit with a physician, no order was found in the clinical record. An LPN confirmed the absence of an order and acknowledged the resident's continuous oxygen use since hospital discharge.
A facility failed to provide trauma-informed care for a resident with PTSD, CHF, and CVA. The resident's care plan did not include PTSD, despite the resident expressing feelings of hopelessness. Staff interviews confirmed that specific care for PTSD should have been documented, as required by the facility's policy. The deficiency was reported to the facility's administrative staff.
A resident did not receive a physician visit for 127 days, exceeding the required 60-day interval for recertification visits. A doctor confirmed the visit schedule, but the facility could not provide a policy for physician visits. The issue was communicated to the facility's leadership team.
A resident with a history of fractures and mobility dependence fell from bed during ADL care when a CNA left her unattended in an unsafe position. The resident attempted to reposition herself and fell, resulting in further fractures. The DON and an LPN confirmed the CNA's actions were unsafe and contributed to the fall.
Inaccurate Resident Assessments in MDS
Penalty
Summary
The facility failed to provide accurate assessments for four residents, leading to deficiencies in their care plans. Resident #25, who was admitted with end-stage renal disease, sepsis, and bilateral osteoarthritis, was not accurately coded for dialysis treatment in the Minimum Data Set (MDS) assessment. Despite having a comprehensive care plan and physician orders indicating dialysis treatment, the MDS did not reflect this, which was acknowledged by the MDS coordinator as an oversight. Resident #124 was incorrectly coded in the MDS as being discharged to a short-term hospital, while documentation showed that the resident was discharged home with their spouse. Similarly, Resident #125 was coded as being discharged home, but records indicated that the resident was transferred to a hospital from a doctor's office due to concerns about a surgical site. These discrepancies were identified during a closed record review and acknowledged by the MDS coordinator, who stated that modifications would be made. For Resident #10, the facility staff failed to complete the pain assessment interview in the MDS. The resident, who was moderately impaired in making daily decisions, was not interviewed for pain, leaving Section J0800 of the MDS blank. The MDS coordinator admitted that the interview should have been conducted and attributed the omission to an oversight. These deficiencies were brought to the attention of the facility's administrative staff, including the administrator and director of nursing, but no further information was provided before the survey exit.
Failure to Develop Baseline Care Plans for New Residents
Penalty
Summary
The facility failed to develop and implement baseline care plans for two residents within 48 hours of their admission, as required by their policy. For one resident, identified as R176, the baseline care plan did not include PTSD, despite the resident having a diagnosis of PTSD, CHF, and CVA. The resident was not cognitively impaired and required moderate assistance for mobility and eating. Additionally, the care plan failed to include monitoring for anticoagulation therapy, even though the resident was prescribed Eliquis, an anticoagulant. Interviews with LPNs confirmed that care plans should include specific care for PTSD and monitoring for anticoagulation therapy. Another resident, identified as R177, was admitted with diagnoses including ESRD, convulsions, and atrial fibrillation. The baseline care plan did not address dialysis, despite the resident having a physician's order for dialysis three times a week. The care plan also failed to include oxygen therapy, even though the resident was prescribed continuous oxygen via nasal cannula. Furthermore, the facility did not implement the fluid restriction as ordered, with records showing repeated exceedances of the prescribed fluid limits. Interviews with LPNs confirmed that care plans should include specific care for residents receiving dialysis and oxygen therapy. The facility's policy requires the development of a baseline care plan within 48 hours of admission to provide effective and person-centered care until a comprehensive assessment and care plan are developed. The deficiencies were brought to the attention of the facility's administrative staff, including the administrator, director of nursing, and regional vice president of operations.
Deficiencies in Care Plan Implementation and Monitoring
Penalty
Summary
The facility staff failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in care. For Resident #15, the staff did not monitor for side effects of anticoagulant therapy as outlined in the care plan. Despite a physician's order for Eliquis, there was no evidence of monitoring for bleeding complications, which is a critical aspect of anticoagulant therapy. Interviews with staff revealed a lack of adherence to the care plan, which should have included regular monitoring and documentation of potential side effects. Resident #75's care plan was incomplete, lacking necessary components for anticoagulation monitoring. The resident, who was severely cognitively impaired, was on Eliquis, yet the care plan did not address monitoring for signs of bleeding or implementing fall prevention strategies. This oversight was acknowledged by the nursing staff, who confirmed that such monitoring should have been included in the care plan to ensure the resident's safety and well-being. For Resident #8, the facility staff failed to administer blood pressure medications and insulin as per physician orders. The care plan required administering medications as ordered, but there were multiple instances where blood pressure medications were given despite contraindications, and insulin doses were missed. Additionally, Resident #70's care plan did not include the use of an elbow splint, despite recommendations from occupational therapy. Observations and interviews indicated that the splinting therapy was not documented or implemented as required, highlighting a gap in the resident's care plan and execution.
Failure to Update Care Plans for Bed Rails and Catheter Use
Penalty
Summary
The facility staff failed to review and revise the comprehensive care plans for four residents, leading to deficiencies in their care. For Resident #23, the care plan did not include the use of bed rails, despite a physician's order and an enabler-restraint observation indicating their necessity for bed mobility and safety. Similarly, Resident #70's care plan lacked documentation of bed rails, which were observed in use and supported by a physician's order and enabler-restraint observation. Licensed Practical Nurse #3 confirmed that the care plans should have included the bed rails to inform staff of their purpose. Resident #20 also had a care plan that failed to document the use of bed rails, even though they were observed in use and supported by a physician's order. The interdisciplinary team did not update the care plan to reflect this, as confirmed by LPN #3. Additionally, Resident #89's care plan did not include documentation related to the use of an indwelling catheter, despite its presence and a physician's order for catheter changes. The Medication Administration Record (MAR) lacked evidence of catheter care, and LPN #4 acknowledged the care plan's role in guiding patient care. The facility's administrative staff, including the administrator and director of nursing, were informed of these concerns, but no further information was provided before the survey exit. The deficiencies highlight a failure to update care plans to reflect current physician orders and observations, which is essential for ensuring appropriate care and safety for residents.
Failure to Administer Medications and Treatments as Ordered
Penalty
Summary
The facility staff failed to administer medications and treatments according to physician orders for two residents, leading to deficiencies in care. For one resident with vascular wounds on both legs, the staff did not apply benzocaine and telfa pads as ordered, resulting in dressings sticking to the wounds and causing pain and bleeding during removal. The resident reported that the facility often ran out of non-adhesive dressings, which contributed to the issue. Observations confirmed that the required telfa pads were not used, and the wound care nurse was unaware of the need to apply benzocaine, indicating a lack of adherence to the physician's treatment plan. Another resident did not receive their prescribed blood pressure medications, amlodipine and carvedilol, as ordered. The medication administration records (MAR) showed instances where the medications were either given despite blood pressure readings below the specified parameters or not documented as administered at all. This inconsistency in medication administration was confirmed through interviews with the resident and staff, highlighting a failure to follow the physician's orders and document the administration properly. Additionally, the same resident experienced issues with insulin administration, with several doses not documented as given according to the MAR. The resident reported not receiving insulin consistently, and the records showed multiple instances of blank entries for insulin administration. This lack of documentation and adherence to the physician's orders for insulin administration further exemplifies the facility's failure to provide care as prescribed, potentially impacting the resident's diabetes management.
Failure to Monitor Fluid Restriction for Resident with ESRD
Penalty
Summary
The facility staff failed to adequately monitor and adhere to fluid restriction orders for a resident, identified as R177, who was admitted with diagnoses including end-stage renal disease (ESRD), convulsions, and atrial fibrillation. The resident was severely cognitively impaired, dependent on others for mobility, transfers, and eating, and required oxygen. The baseline care plan indicated a need for fluid restriction due to increased nutrition and hydration risk. A physician's order specified a fluid restriction of 1200cc per 24 hours, with detailed instructions for distribution between dietary and nursing staff. However, a review of the medication administration records (MAR) for November and December revealed multiple instances where the fluid restriction was exceeded on both day and evening shifts. An LPN confirmed that the fluid restriction orders were not consistently followed, suggesting that agency nurses might not have been aware of the documentation process. The facility's policy required licensed nurses to verify and investigate any variances in fluid intake, but this was not adhered to, leading to the deficiency. The administrative staff, including the administrator, director of nursing, and regional vice president of operations, were informed of these concerns.
Failure to Monitor Anticoagulant Therapy in Residents
Penalty
Summary
The facility staff failed to ensure that two residents, identified as Resident #15 and Resident #176, were free from unnecessary medications due to inadequate monitoring of their anticoagulant therapy with Eliquis. For Resident #15, the clinical record showed a physician's order for Eliquis 5 mg twice daily for atrial fibrillation, but there was no evidence of monitoring for side effects such as bleeding from 11/12/24 to 12/11/24. An LPN confirmed that monitoring for bleeding should be documented on the medication administration record (MAR) as per the facility's anticoagulation policy, which was not done in this case. Similarly, Resident #176, who was admitted with diagnoses including PTSD, CHF, and CVA, was prescribed Eliquis 5 mg twice daily. However, the MAR lacked evidence of anticoagulation monitoring. Interviews with LPNs revealed that monitoring for bleeding and bruising is a standard nursing practice and should be documented on the MAR, but this was not followed. The facility's administrative staff, including the administrator and director of nursing, were informed of these deficiencies, but no further information was provided before the survey exit.
Sanitation and Expired Supplements Deficiency
Penalty
Summary
The facility staff failed to maintain sanitary conditions in the kitchen and nourishment room, as observed during a survey. In the kitchen, two 12-inch round fans located in the dishwasher area were found to have visible dust and rust on their cages. The dietary manager stated that the dietary staff were responsible for cleaning the fans, but the maintenance director, who was new to the facility, was unsure of the cleaning schedule and had not received any requests to clean the fans. The facility's Equipment Cleaning and Sanitation Policy required a comprehensive cleaning schedule, which was not evidenced in practice. In the Unit two nourishment room, seven 8-ounce cartons of Novasource renal 19% nutritional supplement were found with expired use-by dates. The LPN stated that nurses checked the dates of items in the refrigerator, while central supply was responsible for stocking supplements. The central supply staff acknowledged that the expired supplements should have been discarded and noted that the specific supplement was slower to move due to limited resident use. The facility's Nourishments and Supplements Policy did not provide guidance on handling use-by dates, contributing to the oversight.
Failure to Conduct Bed Inspections Prior to Bed Rail Use
Penalty
Summary
The facility staff failed to conduct and document bed inspections for four residents prior to the use of bed rails, as required by the facility's policy. Observations were made of residents in bed with bilateral upper bed rails in place, but there was no evidence of bed inspections for safety prior to their use. The facility's policy mandates that bed inspections should be conducted annually and as needed when bed or mattress configurations change, with inspection checklists maintained for a minimum of three years. For Resident #23, a physician's order indicated the use of bed rails related to bed mobility, but the comprehensive care plan did not document the use of bed rails. Similarly, for Resident #70, a physician's order documented bed rails as tolerated, but the comprehensive care plan failed to evidence their use. Resident #10's comprehensive care plan mentioned bed rails to be used as ordered, but there was no physician order for bed rails. Resident #20 had a physician order for bed rails as tolerated, but the comprehensive care plan did not document their use. The maintenance director, OSM #3, stated that bed inspections were conducted quarterly or at a minimum annually, but he was unable to find any records of inspections prior to a facility-wide inspection conducted on 12/10/24. The lack of documentation and evidence of bed inspections prior to the use of bed rails for these residents was brought to the attention of the facility's administrative staff, including the administrator and director of nursing, but no further information was provided before the survey exit.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility staff failed to assess a resident, identified as Resident #32, for the self-administration of medication, specifically the Breyna respiratory inhaler. During an observation, the inhaler was found on the resident's bedside table, and the resident stated that he keeps it there for use when needed. However, a review of the clinical record did not show any physician order permitting the resident to self-administer the medication, nor was there an assessment conducted to determine the resident's capability to do so safely. Additionally, the comprehensive care plan for the resident, dated several months prior, lacked any documentation regarding self-administration of medications. Interviews with facility staff, including an LPN, revealed a lack of awareness about the requirements for residents to keep medications at the bedside, with the LPN incorrectly stating that the inhaler should not be kept there. The facility's administrative staff, including the administrator and the director of nursing, were informed of the issue, but no further information was provided before the survey exit.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility staff failed to accommodate the needs of a resident, identified as R25, by not ensuring the call light was accessible. R25, who was admitted with diagnoses including end-stage renal disease, sepsis, and bilateral osteoarthritis, was assessed as not cognitively impaired and required supervision for various activities. During an observation, the call bell was found on the floor between beds, and R25 was unaware of its location. This indicates that the resident's needs were not met as they could not reach the call bell when needed. An interview with an LPN confirmed the call device was on the floor and not within reach of R25, which did not accommodate the resident's needs. The facility's policy requires that call lights be within easy reach when residents are in bed or confined to a chair. The deficiency was brought to the attention of the facility's administrative staff, including the administrator, director of nursing, and regional vice president of operations, but no further information was provided before the survey exit.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility staff failed to provide written notification to residents and/or their responsible parties upon transfer to the hospital for three residents. For Resident #16, the staff did not provide a written notification when the resident was transferred to the hospital due to vomiting coffee ground emesis. The responsible party was notified by phone, but no written documentation was given, and the facility lacked a policy for such notifications. Interviews with staff confirmed that written notifications were not provided, and the administration was informed of this issue. Resident #9, who was cognitively intact, was transferred to the hospital without written notification to the responsible party. The resident experienced a rapid decline and was transported by paramedics. Although the responsible party was notified by phone, there was no evidence of written notification. The facility's administrative staff was made aware of the deficiency, but no further documentation was provided to address the issue. For Resident #90, who was severely cognitively impaired, the facility also failed to provide written notification to the responsible party upon transfer to the hospital following an unwitnessed fall. The resident's family was informed by phone, but no written notice was given. The facility's administration was notified of the deficiency, but no additional information was provided before the survey exit.
Failure to Provide Bed Hold Notice for Hospital Transfer
Penalty
Summary
The facility staff failed to provide evidence of a bed hold notice for a facility-initiated transfer of a resident to a hospital. On 11/24/24, paramedics arrived to tend to the resident, who was rapidly declining and required a non-rebreather. The resident was emergently transported to a hospital with necessary documents, including a facesheet, InterAct form, medication list, and DNR form. A message was left with the resident's wife, who is the primary contact and legal representative. However, the clinical record did not show evidence that a bed hold notice was provided to the responsible party for this transfer. Interviews and document reviews revealed that the nursing staff should have sent a bed hold notice with the resident during the transfer, as per facility policy. Despite requests for evidence of the bed hold notice, the facility staff, including the director of nursing and administrative support, failed to provide documentation showing that the notice was given. The facility's Bed Hold Letter Policy requires the business office or designee to complete and send the Medicaid Bed Hold Letter to the appropriate parties, but no such evidence was found in the resident's records.
Failure to Implement Therapy Recommendations for Resident's Mobility
Penalty
Summary
The facility staff failed to provide services to maintain or improve mobility for Resident #70, who was observed with limited range of motion (ROM) in the right hand and without the recommended splinting device. The occupational therapy (OT) evaluation and plan of treatment had recommended the use of a splint to inhibit abnormal reflex patterns and improve finger flexion. However, the comprehensive care plan for the resident did not address the limited ROM or the use of any splinting devices, and there were no physician's orders for the use of a splinting device. Interviews with staff revealed that the director of rehab was aware of the discharge recommendations for restorative nursing and splinting, but the restorative aide was not informed of the treatment until the day of the interview. Documentation showed that passive ROM and splinting had not been completed since late October, despite the therapy referral to nursing for splinting and exercises. The administrative staff was made aware of the concern, but no further information was provided before the survey exit.
Failure to Provide Indwelling Catheter Care
Penalty
Summary
The facility staff failed to provide appropriate care and services for an indwelling catheter for Resident #89. On December 10, 2024, the resident was observed in bed with an indwelling catheter bag hanging off the bedframe. The physician orders from July 8, 2024, indicated that the catheter should be changed as needed, but there was no specific order for regular catheter care. Additionally, the Medication Administration Record (MAR) for October, November, and December 2024 did not contain any documentation of catheter care being provided. The comprehensive care plan dated July 11, 2024, identified urinary incontinence due to muscle weakness, lack of coordination, dementia, and Alzheimer's, but did not include any documentation related to the use of an indwelling catheter. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that there was no evidence of catheter care for the resident. The facility's administrative staff was made aware of the deficiency, but no further information was provided before the survey exit.
Failure to Obtain Physician's Order for Oxygen Administration
Penalty
Summary
The facility staff failed to obtain a physician's order for the administration of oxygen for a resident, identified as Resident #9. The resident was documented to be using oxygen at 2 liters per minute via nasal cannula on multiple occasions, including during a follow-up visit with a physician and after completing antibiotic treatment for pneumonia. Despite the continuous use of oxygen, a review of the resident's clinical record revealed no evidence of an order for oxygen administration. An interview with an LPN confirmed that residents receiving oxygen should have orders, and standing orders are used only in emergencies. The LPN acknowledged that the resident had been wearing oxygen continuously since returning from the hospital, yet no order was placed in the medical record. The facility's policy requires licensed clinicians to administer oxygen as ordered by a provider, with emergency administration allowed only until a provider's order can be obtained. The deficiency was brought to the attention of the facility's administrative staff, including the administrator and director of nursing.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with PTSD, CHF, and CVA. The resident, who was not cognitively impaired, was admitted with PTSD listed on their problem list. However, the baseline care plan did not include PTSD as a problem, indicating a lack of specific care planning for this condition. The resident expressed feelings of hopelessness during a PHQ9 questionnaire, which was reported to the social worker, DON, ADON, and unit manager nurse. Despite these concerns, the resident refused psychiatric intervention and was prescribed Buspar. Interviews with facility staff revealed that there should have been specific care outlined for the resident's PTSD, which should have been documented in the care plan. The facility's Social Services policy requires individualized care plans for trauma and PTSD, but this was not evidenced in the resident's care plan. The deficiency was brought to the attention of the facility's administrative staff, including the administrator, director of nursing, and regional vice president of operations.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility staff failed to ensure timely physician visits for a resident, identified as Resident #127, within the required timeframe. A review of the clinical records revealed that there was no documented physician visit for the resident between June 8, 2021, and October 14, 2021, resulting in a gap of 127 days without a physician's visit. During an interview, a medical doctor confirmed that long-term care residents were supposed to be seen every 60 days for recertification visits, with visits alternated between the doctor and a nurse practitioner. However, the facility was unable to provide a policy for physician visits when requested. The findings were communicated to the facility's administrative and clinical leadership team, but no further information was provided before the survey exit.
Resident Fall Due to Unsafe Positioning During Care
Penalty
Summary
The facility staff failed to ensure the safety of Resident #4 during activities of daily living (ADL) care, resulting in harm. Resident #4, who had a history of a left hip fracture and other significant medical conditions, was assessed as dependent for mobility and required assistance for rolling and positioning in bed. On the day of the incident, Certified Nursing Assistant (CNA) #1 was providing incontinent care to Resident #4 and left the resident unattended on her left side to retrieve clean linen, instructing the resident to roll back to the middle of the bed if needed. While CNA #1 was out of the room, Resident #4 attempted to reposition herself and fell from the bed, sustaining a left hip fracture and a distal right femur periprosthetic displaced comminuted fracture. The resident's cognitive abilities were intact, as indicated by a perfect score on the Brief Interview for Mental Status (BIMS), but she was physically dependent on assistance for safe mobility. The incident occurred because CNA #1 left the resident in an unsafe position, contrary to the resident's care requirements. Interviews with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #1 confirmed that CNA #1's actions were unsafe and contributed to the fall. The DON acknowledged that Resident #4 was dependent for rolling and mobility, and the fall was attributed to CNA #1 leaving the room during care. CNA #1, an agency staff member, was subsequently asked not to return to the facility due to this unsafe practice.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 223 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Portsmouth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Care Of Portsmouth | 2 mi | ★★★★★ | 16 | 0 |
| Deep Creek Health & Rehabilitation | 2.1 mi | ★★★★★ | 13 | 0 |
| Portsmouth Health And Rehab | 4.1 mi | ★★★★★ | 7 | 1 |
| Harbor's Edge | 5.4 mi | ★★★★★ | 2 | 0 |
| Northern Cardinal Rehabilitation And Nursing | 5.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.