Portsmouth Health and Rehab

In the surveyor’s words

From the most serious findings on record at Portsmouth Health and Rehab, in the surveyor’s own words.

• Immediate jeopardy, widespreadF919May 28, 2021

  Based on observations, interviews, and record reviews, the facility failed to have a functioning call system that relayed a call to a staff member or to a centralized staff work area. The failure to have a functional call system resulted in immediate jeopardy for 70 of the 74 residents in the facility. Failure to have a functioning call system had the likelihood to result in harm or death as residents had no means to contact staff. On 05/24/21 at 6:46 PM, the Administrator and Director of Nursing (DON) were notified of an immediate jeopardy at F919-L Resident Call System. The immediate jeopardy began on 05/17/21 when the facility became aware that the call system was not functioning. The facility provided an acceptable plan for removal of the immediate jeopardy on 05/26/21 at 10:51 AM. […]

• Immediate jeopardy, patternF740Mar 22, 2024

  Based on clinical record review, family interview, staff interviews, and review of facility documentation, the facility's staff failed to identify, address, and obtain necessary psychiatric services for the behavioral health care needs of 1 of 15 residents (Resident #1), in the survey sample who had self-harming behaviors that ultimately caused the resident's death and identification of Immediate Jeopardy. The findings included: The facility's staff failure resulted in Resident #1 self-harming behavior on [DATE] by putting her hands around her neck until bruising and bleeding occurred, throwing herself on the floor multiple times and sustaining a left periorbital subcutaneous hematoma on [DATE] and finally on [DATE] the resident swallowed a wooden object which lodged in her throat,… […]

• Immediate jeopardy, patternF741Mar 22, 2024

  Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility failed to provide care that met the needs of residents with mental health disorders and/or behaviors requiring frequent monitoring. The facility staff failed to ensure sufficient staff was provided frequent safety checks with one-to-one supervision by staff to address the resident's behavioral health care needs and safety for 4 of 15 residents (Resident #1, Resident #3, Resident #5, and Resident #11) in the survey sample which resulted in immediate jeopardy. The findings include: 1. […]

• Immediate jeopardy, isolatedF678Sep 19, 2025

  Based on interview, record review, and review of the facility's policy, the facility failed to ensure the nursing staff followed the resident's do not resuscitate (DNR) order for one of three residents (Resident (R) 109) reviewed for advance directives out of 47 sampled residents. On [DATE], R109 was found unresponsive in her room, the nursing staff did not verify her code status prior to providing chest compressions in the absence of a pulse; when the code status was verified the nurse stopped chest compressions and R109 was sent to the hospital. Additionally, the nursing staff were not aware where to locate the code status of the residents during a power outage. […]

• Actual harm, isolatedF760Oct 2, 2024

  Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility staff failed to ensure a resident was free of a significant medication error which resulted in an opioid overdose, which caused harm for 1 of 5 residents (Resident #4), in the survey sample. The findings included: Resident #4 was originally admitted to the facility 9/6/24 after an acute care hospital stay. The resident's admission diagnoses included acute osteomyelitis of the right foot and ankle and chronic pain. The resident had not been admitted to the facility long enough for the Minimum Data Set (MDS) to be completed therefore the following information was obtained from a nurse's note dated 9/6/24 at 11:59 PM. […]