Inspection Reports for The Meadows, a Personal Care Community
2160 WARRENSVILLE ROAD,, MONTOURSVILLE, PA, 17754
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
8.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
79% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
92% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 59
Capacity: 64
Deficiencies: 18
Date: Aug 5, 2025
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 08/05/2025 to review compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including medication administration errors, incomplete resident contracts and records, background check delays, sanitary and safety issues, and failure to report medication errors timely. Plans of correction were submitted and determined to be fully implemented by the follow-up date.
Deficiencies (18)
Staff person signed off on a med pass without administering medications; medication error was not reported to the Department.
Resident-home contract for resident #2 was not signed by the resident.
Resident #2's record lacked a signed statement acknowledging receipt of resident rights and complaint procedures.
Staff person B hired and began working without background clearance initiated.
Direct care staff persons B and C lacked required high school diploma, GED, or active nurse aide registry status.
Brown sticky substance found in bottom drawer of resident's refrigerator in 400 hallway.
Exhaust fans in bathrooms without windows were not operable.
Electrical outlet box pulled out of wall exposing wires in handicap tub room.
Emergency telephone numbers were not posted by the kitchen landline phone.
Expired eggs with expiration date 8/2024 found in west wing refrigerator.
Combustible washcloth lying near electrical outlet with exposed wiring in 400 hallway tub room (repeat violation).
Fire drill during sleeping hours was overdue; last conducted 10/1/24, next required by 4/1/25.
Resident #1 was not administered Donepezil and Enalapril on 1/29/25 at 8:00 p.m.; medications left in hallway outside resident's room.
Lantus insulin pens stored in refrigerator after opening, contrary to manufacturer instructions.
Resident #4's narcotic control log missing initials of staff who administered Tramadol on 7/30/25 at 8:00 a.m.
Resident records for residents #5, #6, #7 lacked identifying marks; Resident #8's record lacked height, weight, and identifying marks.
Medication error involving Resident #1 was not reported to the prescriber.
No documentation of medication error in Resident #1's record.
Report Facts
License Capacity: 64
Residents Served: 59
Total Daily Staff: 59
Waking Staff: 44
Hospice Residents: 2
Inspection Report
Renewal
Census: 42
Capacity: 64
Deficiencies: 8
Date: Aug 13, 2024
Visit Reason
The inspection was conducted as a renewal inspection of THE MEADOWS, A PERSONAL CARE COMMUNITY on 08/13/2024 to assess compliance with licensing requirements.
Findings
The submitted plan of correction was found to be fully implemented. Several deficiencies were identified related to staff hiring procedures, food protection, combustible storage, fire drill records, designated meeting place during fire drills, medication storage, prescription accuracy, and medication storage procedures. All deficiencies had corrective plans accepted and implemented by 09/26/2024.
Deficiencies (8)
Dietary staff person did not have criminal background check completed until after hire date.
A package of individually packaged rice crispies was unsealed, exposing contents to contamination.
Large pile of lint located on the floor behind the dryer in the 200-wing laundry room.
Fire drill records missing year, time of day, and information on problems encountered during drills.
Resident refused to evacuate to designated meeting place during fire drills on 1/5/24 and 2/2/24.
Several unlocked, unattended medications found in Resident #1's bedroom.
Over-the-counter Tylenol 500mg found in Resident #2’s nightstand without a medication order.
Controlled Medication Record was not signed after administration of resident #4's Pregabalin.
Report Facts
License Capacity: 64
Residents Served: 42
Total Daily Staff: 42
Waking Staff: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named in plan of correction monitoring and implementation for multiple deficiencies. | |
| Dietary Manager | Named in plan of correction for food protection deficiency. | |
| Maintenance Supervisor | Named in plan of correction for combustible storage deficiency. | |
| Personal Care Staff Supervisor | Named in plan of correction for medication storage and prescription deficiencies. | |
| Personal Care Shift Supervisor | Named in plan of correction for medication storage and prescription deficiencies. |
Inspection Report
Renewal
Census: 45
Capacity: 64
Deficiencies: 12
Date: Aug 29, 2023
Visit Reason
The inspection was conducted as a renewal inspection of THE MEADOWS, A PERSONAL CARE COMMUNITY to assess compliance with licensing requirements.
Findings
The submitted plan of correction was determined to be fully implemented following the inspection visits on 08/29/2023 and 09/05/2023. Several deficiencies were identified including issues with posting the license inspection summary, obstructed egress, combustible storage, fire safety inspections, annual medical evaluations, medication administration records, and support plan documentation, all of which had corrective plans accepted and implemented.
Deficiencies (12)
The License inspection summary (LIS) report was not posted in the binder containing previous LIS reports.
The dining room exit was blocked by a table and chairs positioned in front of the exit door during the initial walkthrough.
Approximately 5 to 6 cigarette butts were observed in the gravel surrounding the outdoor smoking area cabana near the shrubs.
The home’s annual fire safety inspections were conducted more than 12 months apart.
Sleeping hour fire drills were held with more staff than required and not during sleeping hours.
Resident #1 and Resident #2’s annual documentation of medical evaluation forms were completed more than 12 months apart.
Resident #3 self-administers medications with assistance; assessment documentation was noted.
Resident #4’s insulin doses were not recorded on the Medication Administration Record due to electronic MAR system malfunction.
Resident #4’s insulin administration did not follow prescriber’s orders on multiple occasions; other residents had medication administration issues due to availability or parameters.
Resident #3’s preadmission screening form was not dated to verify completion prior to admission.
Resident #3’s support plan was finalized more than 30 days after admission.
Resident #7’s and Resident #8’s support plans did not reflect updated supervision needs or hospice status.
Report Facts
License Capacity: 64
Residents Served: 45
Total Daily Staff: 45
Waking Staff: 34
Number of cigarette butts observed: 5
Fire safety inspections interval: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Margaret Ergott | Dietary Supervisor | Fixed egress obstruction by shifting table and chairs during inspection |
| Cheryl Sauter | Personal Care Supervisor | Responsible for updating support plans and reviewing medication administration |
Inspection Report
Plan of Correction
Census: 31
Capacity: 64
Deficiencies: 1
Date: Dec 13, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 12/13/2022 to review the implementation of a previously submitted plan of correction related to an incident.
Findings
The plan of correction submitted by the facility was determined to be fully implemented as of the inspection date. The deficiency involved missing narcotic medication tablets that were replaced with rolled up pieces of paper, and corrective procedures for narcotic storage and handling were established and verified.
Deficiencies (1)
On 8/26/22 it was noted that 38 of Resident #1's 1/2 tablets of tramadol were missing and replaced with rolled up pieces of paper. Resident #2's blister pack of lorazepam 1/2 tablets had 3 pills instead of 4 as noted on the narcotic count sheet.
Report Facts
License Capacity: 64
Residents Served: 31
Missing tablets: 38
Lorazepam pills discrepancy: 1
Total Daily Staff: 31
Waking Staff: 23
Inspection Report
Renewal
Deficiencies: 0
Date: Oct 13, 2021
Visit Reason
The inspection was conducted as a licensing inspection of THE MEADOWS, A PERSONAL CARE COMMUNITY.
Findings
No regulatory citations were identified as a result of this inspection.
Notice
Capacity: 64
Deficiencies: 0
Date: Jun 15, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for The Meadows, A Personal Care Community, a Personal Care Home, following receipt of a renewal application.
Findings
The Department confirms receipt of the renewal application and issuance of a regular license. It advises that an onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum capacity: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter. |
Inspection Report
Renewal
Census: 28
Capacity: 64
Deficiencies: 3
Date: May 20, 2021
Visit Reason
The inspection was conducted as a renewal inspection of THE MEADOWS, A PERSONAL CARE COMMUNITY to assess compliance with licensing requirements.
Findings
The facility submitted a plan of correction which was determined to be fully implemented. Deficiencies included evacuation time exceeding the maximum safe limit, incomplete medical evaluation documentation for a resident, and an incomplete smoking policy regarding outdoor smoking areas. All plans of correction were accepted and documented as implemented.
Deficiencies (3)
Evacuation drill exceeded the maximum safe evacuation time of 6 minutes, taking 6 minutes and 37 seconds.
The Documentation of Medical Evaluation form for resident #1 was missing weight, pulse, temperature, and blood pressure information.
The home's smoking policy did not indicate that an outdoor smoking area was provided, despite employees smoking in an outdoor gazebo.
Report Facts
License Capacity: 64
Residents Served: 28
Evacuation Time: 6.62
Staffing: 28
Waking Staff: 21
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