Below 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 Portsmouth Health And Rehab during CMS and state inspections, most recent first.
A resident with a DNR order was found unresponsive and received chest compressions from nursing staff before her code status was verified, despite facility policy requiring verification prior to CPR. Staff interviews revealed inconsistent practices and a lack of awareness about accessing code status during power outages, leading to the failure to honor the resident's advance directive.
A resident was not offered a room change or diversional activities after his roommate died, despite being cognitively intact and facility staff stating this was standard practice. Documentation and interviews confirmed the omission, and the resident reported not being given the option to move rooms.
A resident with a history of behavioral issues became upset after an LPN woke him to administer medications, leading to a confrontation in which the resident threatened the LPN with a wet floor sign. In response, the LPN verbally threatened to strike the resident with a water pitcher. The incident was witnessed by another LPN, who intervened and provided support to the resident. The facility's investigation confirmed that the LPN's actions constituted verbal abuse.
Two residents experienced alleged verbal abuse involving an LPN, with the incident not being reported to the Administrator or State Survey Agency within the required timeframe. The delay occurred because the Administrator was not notified at the time of the incident, and the required reports were only submitted after a concern note was left by staff.
A resident with a history of epilepsy experienced two seizure episodes. During the second, prolonged episode, lorazepam was administered intramuscularly by nursing staff without a current physician order, despite facility policy requiring confirmation of orders prior to medication administration. The medication had previously been discontinued, and staff interviews confirmed it was given without proper authorization.
A resident with a history of intermittent pain following a motor vehicle accident did not receive multiple doses of ordered Oxycodone for chronic pain, and there was no documentation in the EMR explaining the missed doses or pain assessments. Facility policy required pain assessment and documentation, but these actions were not completed as expected.
A discontinued controlled medication, lorazepam, was not removed from the medication cart as required, allowing it to remain accessible. During a seizure episode, a resident with epilepsy was administered this discontinued medication without a current physician order, resulting in unauthorized administration by nursing staff.
A resident experienced an opioid overdose after facility staff failed to remove a previous Fentanyl patch before applying a new one, resulting in two patches being present. The resident was found unresponsive and was hospitalized, where the overdose was confirmed and treated. Staff had received training on Fentanyl patch management, but the error still occurred.
Failure to Honor DNR Order and Verify Code Status Prior to Initiating CPR
Penalty
Summary
The facility failed to ensure that nursing staff followed a resident's do not resuscitate (DNR) order, resulting in the initiation of chest compressions on a resident who had a valid DNR order in place. The resident, who had a diagnosis of pulmonary fibrosis, was found unresponsive in her room by a CNA, who alerted a nurse. The nurse observed the resident to be cyanotic and unresponsive, and called for assistance and a crash cart. Without verifying the resident's code status, another nurse began chest compressions. It was only after another nurse checked and reported the resident's DNR status that chest compressions were stopped. Interviews with staff revealed inconsistent understanding and practices regarding the verification of code status in emergency situations. Some nurses stated they would begin CPR and then verify code status, while others indicated they would check code status first. Additionally, several staff members were unaware of how to access residents' code status during a power outage, as the electronic medical record (EMR) would be inaccessible. This lack of awareness and protocol led to the failure to honor the resident's advance directive. The facility's policy required that code status be checked before initiating CPR, and that residents' advance directives be honored. However, in this incident, the policy was not followed, resulting in the administration of CPR to a resident with a DNR order. The deficiency was identified as Immediate Jeopardy due to the failure to honor the resident's wishes and the lack of staff knowledge regarding code status access during emergencies.
Removal Plan
- Initiate a thorough investigation into the event
- Verify the accuracy for all residents' code status to ensure they align with their wishes
- Provide re-education to all licensed nurses regarding advanced directives and the importance of following physician's orders
- Provide re-education to all licensed nurses on the proper response to an unresponsive resident, as well as code blue and CPR procedures, emphasizing the importance of reviewing advanced directives
- Implement mandatory code blue drills with all licensed nurses and CNAs to reinforce proper response and awareness of advanced directives
- Re-educate all staff members on the definition of neglect, specifically addressing the failure to provide services and care in accordance with a resident's advanced directive wishes
Failure to Offer Room Change or Diversional Activities After Roommate's Death
Penalty
Summary
A cognitively intact resident was not offered the opportunity to move to another room or participate in diversional activities after his roommate passed away. The resident's admission and assessment records indicated he was able to ambulate independently and had a perfect score on the Brief Interview for Mental Status (BIMS), confirming his awareness of the situation. Review of progress notes and interviews with staff confirmed that the facility did not document or offer the resident a room change or alternative activities following the death of his roommate, despite facility policy and staff statements indicating this should have occurred. Multiple staff interviews, including those with the Central Supply Manager, Administrator, LPN, and MDS Coordinator, revealed that it was standard practice to offer a room change or diversional activities to a surviving roommate after a death. However, the resident himself confirmed he was not offered another room. The Administrator also stated there was no specific policy for dignity in such situations. This lack of action and documentation failed to honor the resident's right to a dignified existence and self-determination during a potentially traumatic event.
Failure to Protect Resident from Verbal Threat of Physical Abuse by LPN
Penalty
Summary
A resident with a diagnosis of adjustment disorder with anxiety and a history of behavioral challenges, including cursing, shouting, and difficulty with redirection, was involved in a verbal altercation with an LPN. The incident began when the LPN entered the resident's room to administer medications, waking the resident, who then became upset after perceiving the LPN's actions as aggressive and possibly hearing a derogatory remark. The resident followed the LPN into the hallway, picked up a wet floor sign, and threatened the LPN, escalating the situation. In response, the LPN picked up a water pitcher from the medication cart and verbally threatened to strike the resident if he approached any closer. This exchange was witnessed by another LPN, who intervened by escorting the resident back to his room and providing emotional support. The resident reported the incident immediately and expressed that he felt better after being allowed to vent, though he initially refused further contact with the nurse involved. The facility's internal investigation confirmed that the LPN had verbally threatened the resident, constituting verbal abuse as defined by facility policy. The incident was reported to the state agency, and statements from the involved parties corroborated the sequence of events, including the LPN's admission to making the threat. The resident was cognitively intact at the time of the incident and later reported feeling safe in the facility.
Failure to Timely Report Alleged Abuse to Administrator and State Agency
Penalty
Summary
The facility failed to ensure that a potential allegation of abuse was reported in a timely manner to both the Administrator and the State Survey Agency (SSA) for two of six residents reviewed for abuse. In one case, a resident with a diagnosis of adjustment disorder with anxiety and a BIMS score indicating cognitive intactness was involved in a verbal altercation with an LPN. The resident reported that the LPN shoved medications in his face, leading to a confrontation in which the resident threatened the LPN with a wet floor sign, and the LPN responded by threatening to strike the resident with a water pitcher. The incident was observed by another LPN, who reported it to the on-call manager, but the Administrator was not notified at the time of the incident. The facility's internal investigation confirmed that verbal abuse occurred, but the initial report to the SSA was not submitted until two days after the incident. The Administrator confirmed that she was not informed of the incident when it occurred and did not report it within the required two-hour timeframe. The required initial and 5-day follow-up reports to the SSA were also not submitted within the mandated timeframes. The delay in reporting was due to the incident only being brought to the Administrator's attention after a concern note was left by the LPN two days later.
Administration of Controlled Substance Without Physician Order During Seizure Event
Penalty
Summary
Nursing staff failed to ensure that care was provided in accordance with professional standards of practice when lorazepam, a controlled substance, was administered to a resident experiencing seizures without a current physician's order. The facility's policies required that medications be administered only as prescribed and that orders be confirmed prior to administration. The resident, who had a history of epilepsy with status epilepticus, had a previous order for lorazepam for agitation, but this order was discontinued and not active at the time of the incident. On the day of the incident, the resident experienced two episodes of seizures. During the first episode, the nurse attempted to contact the physician for an order to administer lorazepam but was unable to reach them and was advised by the on-call nurse not to administer the medication without explicit approval. During the second, prolonged seizure episode, another nurse insisted that lorazepam be administered due to the emergency nature of the situation, and the medication was given intramuscularly without a current order while the resident was still seizing. Emergency medical services were called, and the resident was subsequently transported to the hospital. Interviews with facility staff, including the DON, PA, and Medical Director, confirmed that the administration of lorazepam occurred without a valid physician's order and that this action was outside the nursing scope of practice. The incident was substantiated through internal investigation and staff interviews, which verified that the medication was administered from discontinued stock and without proper authorization.
Failure to Administer and Document Ordered Pain Medication
Penalty
Summary
The facility failed to ensure that narcotic pain medication was administered as ordered for a resident with a history of intermittent pain following a motor vehicle accident. The resident, who was cognitively intact and able to ambulate independently, had a physician's order for Oxycodone 5 mg every six hours for chronic pain. Despite this order, the Medication Administration Record (MAR) showed multiple missed doses of the prescribed pain medication on several dates across two consecutive months. There was no documentation in the resident's progress notes explaining why the pain medication was not administered or why pain assessments were not completed at those times. Facility policy required residents to be assessed for pain at specific intervals and when experiencing new or uncontrolled pain. The care plan for this resident included medicating for pain as ordered and following up for effectiveness. However, the facility did not document any assessments or reasons for withholding the medication on the missed dates. During an interview, the Director of Nursing confirmed that the expectation was for nurses to document the reason in the EMR if a routine pain medication was not given, which was not done in this case.
Failure to Remove and Destroy Discontinued Controlled Medication
Penalty
Summary
The facility failed to remove and destroy a discontinued controlled medication, lorazepam, as required by its own policy and federal/state regulations. After a physician's order for lorazepam injection was discontinued, the medication remained in the medication cart instead of being removed and secured for destruction by the Director of Nursing and another nurse. This lapse in procedure allowed the discontinued medication to remain accessible to staff. Subsequently, a resident with a history of epilepsy and recent seizure activity was administered the discontinued lorazepam during an episode of active seizure, despite there being no current physician order for its use. The medication was located in the narcotic drawer and given intramuscularly by a registered nurse after consultation with another nurse. The failure to remove and destroy the discontinued controlled substance directly led to its unauthorized administration to the resident.
Resident Overdose Due to Fentanyl Patch Error
Penalty
Summary
The facility staff failed to ensure that a resident was free from significant medication errors, resulting in an opioid overdose for Resident #4. The resident was admitted to the facility with acute osteomyelitis and chronic pain, and had a physician's order for a Fentanyl Transdermal Patch to be applied every three days for pain control. However, the Medication Administration Record (MAR) indicated that a new patch was applied without removing the previous one, leading to the resident having two patches on their body. On the morning following the application of the second patch, the resident was found unresponsive with a low blood oxygen level, pinpoint pupils, and only responded to a sternal rub. Emergency services were called, and upon arrival at the hospital, the resident's condition was confirmed as an opioid overdose due to the presence of two Fentanyl patches. The hospital staff removed the patches and administered Narcan, which immediately revived the resident. Interviews with facility staff revealed that they had recently received in-service training on the proper handling of Fentanyl patches, including the importance of checking for existing patches and ensuring their removal before applying new ones. Despite this training, the oversight occurred, leading to the resident's overdose and subsequent hospitalization.
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 240 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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) |
|---|---|---|---|---|
| Harbor's Edge | 1.4 mi | ★★★★★ | 2 | 0 |
| Signature Healthcare Of Norfolk | 2 mi | ★★★★★ | 0 | 0 |
| Autumn Care Of Portsmouth | 2.3 mi | ★★★★★ | 16 | 0 |
| Norfolk Health Care Center | 2.3 mi | ★★★★★ | 13 | 1 |
| Ghent Health And Rehabilitation | 3.4 mi | ★★★★★ | 34 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Portsmouth Health And Rehab.
100% money-back within 48 hours.
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.