Meadowview Rehab: DNR Order Ignored at Death - PA
What happened next was thorough. Staff performed cardiopulmonary resuscitation until paramedics arrived. Paramedics administered epinephrine, four or five rounds of it, trying to restart the heart. None of it worked. A physician called the time of death. A nurse phoned the resident's sister to say that her sibling had died unexpectedly and to ask about arrangements.
None of it should have happened. The resident, identified in inspection records as Resident R2, had a Do Not Resuscitate order on file. Two of them, in fact.
A state inspection completed August 28, 2025, at Meadowview Rehabilitation and Nursing Center found that the facility failed to follow physician orders for Resident R2, who had been admitted to the facility on July 10, 2025. The inspection was triggered by a complaint. The finding was cited at a level of minimal harm or potential for actual harm, though the Director of Nursing confirmed during an interview with inspectors that the facility had failed to implement the code status order.
Resident R2 had been admitted carrying a serious constellation of diagnoses. Combined systolic and diastolic heart failure, meaning the heart was struggling both to pump blood out and to fill properly with blood. Pericardial effusion, meaning excess fluid had built up in the sac surrounding the heart. Pleural effusion, meaning fluid had accumulated between the lungs and the chest wall. And thrombocytopenia, a condition that reduces the blood's ability to clot, leaving a person vulnerable to excessive bleeding and bruising. These were not incidental conditions. They were the medical backdrop against which this resident had made decisions about how they wanted to die.
Those decisions were documented. Resident R2's clinical record contained a Pennsylvania Orders for Life Sustaining Treatment form, known as a POLST, designating the resident's code status as DNR, Do Not Attempt Resuscitation. The electronic clinical record contained a separate physician order, also designating the resident as DNR. The order was there. The form was there. Both said the same thing.
At 3 a.m., neither one was followed.
The nurse who documented the events, Employee E5, recorded the sequence in a nursing progress note. The roommate's alert. The slow, shallow breathing. The oxygen saturation reading of 84. The oxygen mask. The call to the nursing supervisor. Then, before the supervisor arrived: the foam at the mouth, the unresponsiveness, the Code Blue, the 911 call, the CPR, the paramedics, the epinephrine, the death.
The note does not indicate that anyone paused to check the chart. It does not indicate that anyone consulted the POLST form before initiating resuscitation. The sequence reads as a practiced emergency response, the kind of thing staff are trained to do when a patient goes down, applied to a patient who had explicitly said she did not want it.
There is a specific cruelty in this kind of failure that is different from other nursing home violations. A resident who develops a bedsore because staff didn't reposition them frequently enough suffers from neglect. A resident who doesn't receive a medication on schedule suffers from a breakdown in routine. But a resident who spent time, at some point before their death, making a legal decision about the manner of their dying, and who had that decision documented in two separate places in their chart, and who still had CPR performed on them and epinephrine injected into them as they died, that resident was failed in a way that cannot be undone and cannot be corrected after the fact.
The DNR designation exists precisely for moments like 3 a.m., when a supervisor hasn't reached the unit yet and a resident is unresponsive and the instinct of everyone in the room is to do something. The order is supposed to answer the question before the question gets asked. At Meadowview on the night Resident R2 died, it didn't.
Federal and state inspection records use careful, distanced language. The finding says the facility "failed to implement the Physician Order pertaining to Resident R2's code status/DNR status." The Director of Nursing, in an interview at 1:22 p.m. on the day of the inspection, confirmed this. The inspection cites violations of Pennsylvania nursing home regulations covering management and nursing services.
What the clinical record shows, underneath that language, is a person who died the way they said they did not want to die, surrounded by people trying to save them.
Meadowview Rehabilitation and Nursing Center is located in White Marsh, Pennsylvania. The inspection covered a review of eight residents' clinical records. The DNR failure was found in one of them, Resident R2's.
That the failure affected only one resident in the sample does not make it a narrow finding. DNR orders exist because people invoke them specifically for the worst moments, the moments when they can no longer speak for themselves, the moments when someone else will have to make the call. The entire weight of a DNR order rests on the assumption that the people in the room will check before they act. Inspectors found that at Meadowview, on the night of Resident R2's death, they did not.
The inspection report does not describe what Resident R2's final weeks at the facility looked like. It does not say whether the resident knew their code status was on file, whether they had discussed it with family, whether the sister who received the 3 a.m. phone call knew that her sibling had asked not to be resuscitated and was told that the facility had done it anyway. The report records only that the call was placed, that the nurse told the family of the resident's "untimely passing," and that arrangements were discussed.
The sister, somewhere on the other end of that call, learned that her sibling was dead. What she was told about the hours before that, the Code Blue, the CPR, the rounds of epinephrine, the sequence of interventions her sibling had already said no to, the inspection report does not say.
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.
Download the official CMS inspection PDF from Medicare.gov
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: September 22, 2026 · Our methodology
MEADOWVIEW REHABILITATION AND NURSING CENTER in WHITE MARSH, PA was cited for violations during a health inspection on August 28, 2025.
What happened next was thorough.
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.