Galion Meadows: DNR Order Ignored After Admission - OH
The man, identified in inspection records as Resident 59, was admitted to Galion Meadows Skilled Nursing and Rehabilitation on May 14, 2026. His diagnoses included a fracture of the upper left arm, acute respiratory failure, chronic obstructive pulmonary disease, atherosclerotic heart disease, dementia, depression, and anxiety. A Medicare assessment completed shortly after admission found he had severe cognitive impairment and needed assistance with nearly every basic activity, from eating to putting on his shoes.
His sister had told the facility at admission that her brother had a DNR order.
A physician order dated May 17 listed his code status as DNRCC-A, a do-not-resuscitate designation that means no cardiopulmonary resuscitation and no transfer to an acute care hospital. But that same day, a care plan entry recorded him as full code. Inspectors found no indication of any code status at all in the initial electronic medical record.
The director of nursing, interviewed on May 18, explained the facility's practice plainly. If a DNR order is entered without a signed paper form, she said, the facility switches the resident to full code until a physician completes the paperwork. She said this is standard procedure and that families are told at admission.
The signed DNRCC-A order wasn't uploaded until May 19, five days after he arrived.
His sister, reached by inspectors on May 18, said she remembered telling staff her brother had a DNR. She wasn't certain whether it was a DNRCC or a DNRCC-A. What she was certain of was that he had one.
The gap between what a family communicated and what the facility recorded as the resident's official status lasted at minimum two days, during which time a man with severe dementia, acute respiratory failure, and heart disease was on record as wanting every intervention available, regardless of what he or his family had actually said.
The facility's own advance directive policy stated that code status decisions would be documented in the medical record and communicated to the interdisciplinary team. The do-not-resuscitate policy required physician signatures on the physician order sheet maintained in the resident's chart. Neither policy addressed what should happen to a resident's stated wishes in the interim, and neither prevented the facility from simply defaulting to full code while it waited on forms.
Inspectors cited the deficiency at a level of minimal harm or potential for actual harm, affecting a small number of residents.
That classification reflects what didn't happen during those days, not what could have. A man with acute respiratory failure and heart disease, in a facility that had recorded him as full code, was at risk of receiving resuscitation he had specifically declined. His sister had already told them. The physician had already written the order. The only thing missing was a signature on a piece of paper, and the facility's response was to set aside the expressed wish entirely until the paperwork caught up.
The signed form arrived on May 19. Whether anyone told his sister that her brother had been listed as full code in the days before that, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Galion Meadows Skilled Nursing and Rehabilitation from 2026-05-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 17, 2026 · Our methodology
Galion Meadows Skilled Nursing and Rehabilitation in GALION, OH was cited for violations during a health inspection on May 26, 2026.
The man, identified in inspection records as Resident 59, was admitted to Galion Meadows Skilled Nursing and Rehabilitation on May 14, 2026.
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.