Portsmouth Health and Rehab: DNR Ignored During Outage - VA
That admission came during a federal inspection completed September 19, 2025, and it sits at the center of a finding that regulators classified as immediate jeopardy, the most serious level of harm a nursing home can receive. The citation describes a failure with consequences that cannot be undone for the resident at the middle of it.
A certified nursing assistant and an LPN found Resident 109 unresponsive in her room. They began chest compressions. She had a do-not-resuscitate order on file. Nobody checked it, because the electronic medical record was down, and staff had no backup plan they could find or use.
The physician assistant who was present at the facility that day told inspectors she expected staff to start CPR on any unresponsive resident until they could determine code status. But she also confirmed what had happened: staff had not honored Resident 109's wishes. The PA said she was concerned the facility had no accessible record of resident code statuses when the power failed and the electronic system went dark.
The LPN interviewed during the investigation, identified in the report as LPN7, said plainly that she did not know where to find the code status of residents when the power went out and the electronic medical record could not be accessed.
A backup system did exist. The social services director told inspectors that when she started at the facility, she had conducted an audit of resident code statuses and assembled a binder. The binder contained copies of DNR orders, the CPR and advance directive policy, and a daily census for each unit. She placed one at each of the two nurses' stations in the building, specifically for use during a power outage.
The binder was there. Staff didn't use it, and the record does not establish that they knew it existed.
The medical director told inspectors he expected nursing staff to follow code status orders and that a DNR means no CPR. He said code status should be verified in the computer first. He also noted that Resident 109 was sent to the hospital and returned unharmed.
That last detail, offered as a kind of resolution, does not change what happened in the room. A woman had decided, in advance and in writing, that she did not want her chest compressed if her heart stopped. That decision was recorded. It was filed. A binder containing a copy of it was sitting at the nurses' station down the hall.
The power failed, and nobody reached for it.
Advance directives exist precisely for moments when the situation is urgent and chaotic and there is no time to search a database. The whole point is that the answer is already written down somewhere a person can put their hands on it in seconds. Portsmouth Health and Rehab had built that system. The social services director had done the work. The binders were placed. And when the moment came, the staff at Resident 109's bedside did not know the binders were there.
Federal inspectors assigned the deficiency an immediate jeopardy designation, meaning the facility's failure created a situation likely to cause serious injury, harm, or death. The citation falls under a regulation requiring facilities to honor each resident's right to refuse treatment and to have their advance directives followed.
Resident 109 went to the hospital. She came back. The medical director described her as unharmed. But she was subjected to a resuscitation attempt she had explicitly refused, in a moment when she could not speak for herself, because the people responsible for her care could not find a piece of paper that was within walking distance of where she lay.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Portsmouth Health and Rehab from 2025-09-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 28, 2026 · Our methodology
PORTSMOUTH HEALTH AND REHAB in PORTSMOUTH, VA was cited for violations during a health inspection on September 19, 2025.
The citation describes a failure with consequences that cannot be undone for the resident at the middle of it.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.