Meadowview Rehab: DNR Order Ignored, CPR Performed - PA
The nurse entered the room and found the resident, identified in inspection records as Resident R2, breathing slowly and shallowly. An oxygen monitor showed a reading of 84 percent, well below the 96 to 99 percent range considered normal. Staff put an oxygen mask on the resident and called the nursing supervisor to come assess.
The supervisor never made it to the unit in time. Before she arrived, the resident was found unresponsive, with foam coming from the mouth. What happened next is documented in a nursing progress note and confirmed by the facility's own Director of Nursing: staff called a Code Blue and dialed 911. Nurses began CPR. Paramedics arrived and administered four to five rounds of epinephrine. The resuscitation was unsuccessful. A physician called the time of death. A nurse then called the resident's sister to deliver the news and discuss arrangements.
Resident R2 had a signed Do Not Resuscitate order.
The order was in two places in the clinical record. A Pennsylvania Orders for Life Sustaining Treatment form, known as a POLST, documented the resident's wishes. A separate physician order in the electronic record said the same thing: Do Not Resuscitate. The resident had been admitted to Meadowview just weeks earlier, on July 10, 2025, carrying a serious cluster of cardiac and blood conditions, including combined systolic and diastolic heart failure, pericardial effusion, pleural effusion, and thrombocytopenia, a low platelet count that impairs the blood's ability to clot. This was not a healthy person who had signed a DNR as a precaution. This was someone whose body was already under significant strain, who had made a documented decision about what they wanted done if their heart stopped.
That decision was not honored.
Federal inspectors cited Meadowview for the violation following a complaint inspection completed August 28, 2025. The deficiency, catalogued under F0684, covers the requirement that facilities follow physician orders and respect residents' preferences and goals. Inspectors reviewed eight residents' clinical records during the survey. Meadowview failed on one of them. That one failure meant a person died in a manner they had explicitly said they did not want.
The Director of Nursing, interviewed on the day of the inspection at 1:22 p.m., confirmed it outright. The facility, she acknowledged, had failed to implement the physician order pertaining to Resident R2's code status.
There is a specific reason DNR orders exist in nursing homes, and it is not bureaucratic. Many residents who choose DNR status are doing so because they understand, or their physicians have helped them understand, that resuscitation in their condition is unlikely to restore meaningful function and is certain to be physically violent. CPR involves repeated, forceful compression of the chest, hard enough and fast enough to circulate blood artificially. Ribs break. It is not a gentle intervention. Epinephrine, pushed into the body in multiple rounds, floods the system with adrenaline in an attempt to restart a heart that has stopped. For a resident already living with heart failure on both sides of the cardiac cycle, with fluid around the heart and around the lungs, the calculus of whether to pursue that course was one Resident R2 had already made. The answer was no.
The inspection report does not explain how the DNR order was missed. It does not say whether the nurse who initiated the Code Blue was unaware of the order, whether the order was visible in the system at the time, or whether there was a communication breakdown between staff on the overnight shift. What it says is that the order existed, that it was documented in the clinical record, and that it was not followed.
It also does not say what the resident's sister said when the nurse called at some point after the time of death was recorded. The report notes only that the call was made to inform the family of the resident's "untimely passing" and to discuss arrangements. Whether the family knew, in that moment or later, that their relative had received CPR and epinephrine against their documented wishes is not recorded.
The harm level assigned to the deficiency is listed as "minimal harm or potential for actual harm," which is the lowest tier in CMS's classification system. That designation reflects a regulatory framework, not a moral one. The resident is dead. The question the framework is designed to answer is whether the violation caused physical harm beyond what would have occurred anyway, and in a case where the resident died regardless, the answer the system produces is: minimal. What the framework does not measure is what it means to die in a way you said you did not want, surrounded by people performing procedures you had legally refused, in the final minutes of your life.
Meadowview is a rehabilitation and nursing center. Residents admitted for cardiac recovery or post-acute care arrive with complex conditions and, often, complex end-of-life documentation. The POLST form in Pennsylvania is specifically designed to travel with a patient, to be visible, to be actionable. It is not a form buried in an admission packet. It is meant to be the first thing staff reach for in exactly the situation that unfolded in that room at 3 a.m.
The inspection covered a small number of records. Eight residents. One failure. But that one failure was not a missed medication dose or a skipped repositioning. It was the override, whether intentional or inadvertent, of a dying person's most fundamental documented instruction about their own body.
The resident's roommate was the one who raised the alarm. That detail sits quietly in the nursing progress note, easy to pass over. Someone in the next bed, woken in the middle of the night, looked over and knew something was wrong, and called for help. What followed, the oxygen mask, the supervisor call, the Code Blue, the CPR, the epinephrine, the paramedics, was help of a kind. It was not the kind Resident R2 had asked for.
The sister received the call after the physician had already declared the time of death. By then, everything that was going to happen had happened.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Meadowview Rehabilitation and Nursing Center from 2025-08-28 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: July 1, 2026 · Our methodology
MEADOWVIEW REHABILITATION AND NURSING CENTER in WHITE MARSH, PA was cited for violations during a health inspection on August 28, 2025.
The nurse entered the room and found the resident, identified in inspection records as Resident R2, breathing slowly and shallowly.
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.