Inspection Reports for
Wesbury United Methodist Community
31 NORTH PARK AVENUE,, MEADVILLE, PA, 16335
Back to Facility Profile20 Reports
Inspection Report — Mar 3, 2026
Follow-Up
Date: Mar 3, 2026
Visit Reason
The inspection was a partial, unannounced visit conducted as a follow-up to a complaint investigation to verify correction of previous deficiencies.
Complaint Details
The inspection was conducted due to a complaint. The submitted plan of correction was fully implemented as of the inspection date.
Findings
The submitted plan of correction was determined to be fully implemented. The inspection identified medication administration errors involving incorrect resident medication administration, with corrective education and monitoring planned and implemented.
Citations (2)
182c Medication Administration: A resident was administered medications prescribed to another resident. The medication administration process was reviewed and education was provided to prevent recurrence.
187d Follow Prescriber's Orders: The home failed to follow the directions of the prescriber by administering medications to the wrong resident. Corrective education and monitoring were implemented.
Report Facts
Residents Served: 58
Total Daily Staff: 60
Waking Staff: 45
Inspection Report — Jan 13, 2026
Renewal
Date: Jan 13, 2026
Visit Reason
The inspection was conducted as a renewal inspection combined with a complaint investigation at the facility.
Complaint Details
The inspection included a complaint investigation related to resident safety and care concerns, including exit seeking behavior and medication management.
Findings
Multiple deficiencies were identified including sanitary conditions, uncovered trash receptacles, lack of operable bedside lamps, outdated food, insufficient emergency food supply, incomplete first aid kits, unsecured medications, presence of discontinued medications, missing prescribed medications, incomplete resident assessments, and use of non-standardized forms. All deficiencies had plans of correction accepted and were implemented by March 5, 2026.
Citations (11)
85a - Sanitary conditions were not maintained; dried, dark brown spots resembling feces were found inside the toilet in resident #1’s private bathroom.
85d - Trash receptacles in kitchens and bathrooms were not kept covered; a garbage can near the stove in the main kitchen lacked a lid.
101j7 - Resident #2 did not have access to an operable lamp or source of lighting that could be turned on/off at bedside.
103i - Outdated or spoiled food was present; an opened and undated bag of peas was found in the main kitchen's walk-in freezer.
107c - The home did not maintain at least a 3-day supply of nonperishable food and drinking water for residents; no emergency food was present.
171b5 - The first aid kit in the passenger van used to transport residents was missing a pair of scissors.
181d - Resident #3 stored medications unlocked and unattended on the bedside table in an unlocked bedroom.
183d - Discontinued medication was present; fifty-seven 0.5mg tablets of Lorazepam belonging to resident #4 were found despite being discontinued.
185a - Medication prescribed to resident #4 was not available in the home as required.
225c - Resident #2 exhibited exit seeking behaviors and was found outside the home during the night, but this change was not documented in the resident’s assessment.
251c - Resident #2 and #6’s annual medical evaluations were not completed on the Department’s current standardized forms.
Report Facts
Residents served: 59
Current Hospice Residents: 1
Residents aged 60 or older: 58
Residents diagnosed with mental illness: 13
Residents diagnosed with intellectual disability: 1
Residents with mobility need: 4
Residents with physical disability: 1
Discontinued Lorazepam tablets found: 57
Inspection Report — Jan 15, 2025
Renewal
Date: Jan 15, 2025
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 01/15/2025 to review the facility's compliance with licensing requirements.
Findings
The facility was found to have multiple deficiencies including delayed access to staff records, incomplete criminal background checks for some staff, insufficient first aid/CPR trained staff coverage, incomplete staff training plan content, and incomplete documentation in resident support plans. Plans of correction were submitted and accepted with completion dates ranging from February to December 2025.
Citations (5)
Delayed access to staff records requested by Department agents on 1/15/25.
No criminal history background check was completed for staff person D; background checks for staff persons A, B, and C were delayed but eventually provided.
Insufficient first aid/CPR trained staff present during multiple shifts when 54 residents were in the home.
The 2025 Staff Training Plan did not include the name, position and duties of each direct care staff person or locations of scheduled training.
Resident support plans for two residents did not include necessary information about use of enabler bar, bedrail, and vision problems.
Report Facts
Residents served: 54
Total daily staff: 57
Waking staff: 43
Residents with mobility need: 3
Residents aged 60 or older: 54
Inspection Report — Apr 23, 2024
Follow-Up
Date: Apr 23, 2024
Visit Reason
The inspection visit on 04/23/2024 was a partial, unannounced follow-up inspection triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction related to medication administration errors was found to be fully implemented. The facility demonstrated ongoing compliance with medication management procedures, including re-education of staff and scheduled audits.
Citations (2)
Medication was administered to the wrong resident, violating the requirement that prescription medications be used only by the resident for whom prescribed.
Failure to follow prescriber's orders resulting in a resident not receiving prescribed medications as directed.
Report Facts
Residents Served: 60
Total Daily Staff: 65
Waking Staff: 49
Residents Age 60 or Older: 59
Residents with Mobility Need: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN Nurse Manager | Responsible for root cause analysis, re-education of Med Tech staff, and conducting unannounced medication audits |
Inspection Report — Dec 14, 2023
Renewal
Date: Dec 14, 2023
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements and verify the implementation of the submitted plan of correction.
Findings
The facility was found to have multiple deficiencies related to staff training, labeling of poisonous materials, trash receptacle coverage, hot water temperature, food storage, lint removal, rabies vaccination, fire drills, medical evaluations, medication labeling, and resident assessments. All deficiencies had plans of correction accepted and were implemented by the report date.
Citations (13)
Staff person A did not receive 12 hours of annual training in training year 2022.
Staff person A did not receive training in required topics including medication self-administration, dementia care, infection control, personal care needs, and safe management techniques during training year 2022.
Staff person A did not receive training in fire safety, emergency preparedness, resident rights, Older Adult Protective Services Act, and falls prevention during training year 2022.
Unlabeled spray bottles containing poisonous materials were found in the kitchen.
Uncovered trash cans in the kitchen and dishwash room.
Hot water temperature exceeded 120°F in multiple resident-accessible sinks.
Food stored on the floor in the main kitchen walk-in freezer.
Accumulation of lint in lint traps of industrial dryers.
Resident's cat did not have a current rabies vaccination certificate.
Fire drill during sleeping hours was not conducted as required.
Resident medical evaluations were not completed or documented as required.
OTC medications and CAM were not labeled with the resident's name.
Resident initial and additional assessments did not include all required diagnoses.
Report Facts
Inspection Dates: 3
Staffing Hours: 69
Waking Staff: 52
Residents Served: 64
Hot Water Temperature: 135.5
Trash Can Size: 55
Trash Can Size: 30
Lint Accumulation: 1
Inspection Report — Apr 27, 2023
Complaint Investigation
Date: Apr 27, 2023
Visit Reason
The inspection was conducted as a complaint investigation following allegations of resident abuse involving staff person A and resident #1.
Complaint Details
The complaint involved an incident where staff person A forcibly administered medication to resident #1 without applesauce or water, causing the resident to refuse initially and later fear the staff member. The incident was reported late to the local Area Agency on Aging and the Department. The complaint was substantiated with corrective actions taken including staff suspension, termination, and education.
Findings
The investigation found that staff person A forcibly administered medication to resident #1 without proper consent, causing fear in the resident. The abuse was not reported timely to the appropriate authorities. Corrective actions including staff education, suspension, and termination of the alleged perpetrator were implemented.
Citations (2)
Failure to immediately report suspected abuse of a resident as required by law.
Resident abuse involving forced medication administration and intimidation.
Report Facts
Residents Served: 40
Number of Pills: 5
Staff Total Daily: 41
Waking Staff: 31
Current Hospice Residents: 1
Residents Age 60 or Older: 40
Inspection Report — Dec 13, 2022
Renewal
Date: Dec 13, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility license, including a full unannounced review from 12/13/2022 to 12/15/2022.
Findings
The inspection found multiple deficiencies including incomplete financial records for residents, unsigned contracts by payers, lack of staff orientation on fire safety and abuse reporting, unsecured resident equipment posing fall hazards, unsecured medications, discontinued medications present, incorrect medication records, and missing times on medication administration records. All deficiencies had plans of correction accepted and were implemented by January 2023.
Citations (9)
Resident #1 and #2 financial records did not include the resident’s account balance.
Resident #3 and #2 resident/home contracts were not signed by the payer as required.
Staff person A had no record of receiving orientation on fire safety and emergency preparedness topics on first day of work.
Staff person A had no record of receiving orientation on resident rights, emergency medical plan, mandatory abuse reporting, and reporting of incidents within first 40 scheduled working hours.
Bed enabler attached to resident #4’s bed was unsecured, causing a potential fall hazard.
Unattended, unsecured, and accessible Preparation H ointment found in resident #5’s bathroom.
Discontinued medication Coricidin HBP found in resident #3’s medication cart.
Multiple incorrect blood glucose readings entered into resident #3’s medication administration record.
Resident #2, #3, #4, and #5 December 2022 Medication Administration Records did not indicate the time of administration for multiple medications.
Report Facts
Residents Served: 56
Total Daily Staff: 60
Waking Staff: 45
Hospice Residents: 2
Residents with Mobility Need: 4
Residents Diagnosed with Intellectual Disability: 1
Inspection Report — Nov 8, 2021
Renewal
Date: Nov 8, 2021
Visit Reason
The document summarizes the results of multiple licensing inspections conducted on 09/29/2021, 10/25/2021, 10/28/2021, 11/01/2021, and 11/08/2021 for the facility.
Findings
No regulatory citations were identified as a result of these inspections.
Report Facts
Inspection dates: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Duncan | Signed the letter summarizing inspection results |
Inspection Report — Aug 25, 2021
Renewal
Date: Aug 25, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility license, with an unannounced full inspection on 08/25/2021 and an exit conference on 08/26/2021.
Findings
The inspection identified several deficiencies including missing resident-home contract, unsecured enabler bar posing entrapment hazard, lint accumulation in dryer lint traps, overdue fire extinguisher inspection on the facility bus, improperly calibrated glucometer, missed blood glucose check, and incomplete medication administration training records. Plans of correction were accepted and implemented for all deficiencies.
Citations (7)
Resident #1 did not have a resident-home contract completed.
Resident #2 has an enabler bar on bed not secured, posing an entrapment hazard.
Approximate 1/4 inch lint accumulation in lint trap of commercial dryer #3 and 1/2 inch in dryer #5.
Fire extinguisher in 2018 Ford Bus used to transport residents had not been inspected since March 2020.
Resident #3's glucometer was not calibrated to the correct date (8/25/21).
Resident #3 missed a prescribed blood glucose check on 8/24/21 at 4:00 p.m.
Medication administration training record for staff person A does not include the date of recertification.
Report Facts
Residents Served: 63
Staffing: 70
Waking Staff: 53
Current Hospice Residents: 1
Residents with Mobility Need: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in medication administration training record deficiency. | |
| RN Nurse Manager | RN Nurse Manager | Provided staff training and audited glucometers and medication technician records. |
| RN Nurse Supervisor | RN Nurse Supervisor | Maintains and reviews medication technician records and recertifications. |
Notice — Mar 25, 2021
Date: Mar 25, 2021
Visit Reason
The document serves as a certificate of compliance and notification of license renewal for Wesbury United Methodist Community, a Personal Care Home, confirming the facility's authorized capacity and informing about the requirement for an annual onsite inspection within the next twelve months.
Findings
The Department has issued a regular license in response to the renewal application and advises that an annual inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Inspection Report — Dec 28, 2020
Complaint Investigation
Date: Dec 28, 2020
Visit Reason
The inspection was conducted as a complaint investigation with a partial, unannounced visit on 12/28/2020 and 12/29/2020.
Complaint Details
The inspection was complaint-driven and no deficiencies were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 66
Inspection Report — Mar 24, 2020
Renewal
Date: Mar 24, 2020
Visit Reason
The document is a renewal application and license issuance for Wesbury United Methodist Community to operate a Personal Care Home. The Department will conduct an onsite inspection within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Nov 5, 2019
Renewal
Date: Nov 5, 2019
Visit Reason
The inspection was conducted as a renewal visit to review compliance and verify the implementation of the submitted plan of correction for Wesbury United Methodist Community.
Findings
The facility was found to have multiple violations including improper handling of resident funds, physical hazards, inadequate bedside lighting, lack of thermometer in kitchen refrigeration, expired medications, and absence of a written emergency medical plan. All identified violations had plans of correction that were fully implemented by the facility.
Citations (8)
The home held in excess of $200.00 for residents #5 and #6 from August to November 2019 without offering assistance to set up interest bearing accounts in the residents' names.
The hinges on the closet door frame were removed from the bedroom of resident #4, posing a laceration hazard until they were removed on 11/07/2019.
Residents #7 and #8 did not have access to a source of light that could be turned on or off at bedside until lighting was provided on 11/6/2019.
There was no thermometer in the refrigerator or freezer in the activities room kitchen until thermometers were placed on 11/5/19.
Dented cans of chunk light tuna and chocolate fudge pudding were found in storage until removed on 11/5/19.
The home did not have a written emergency medical plan until one was developed on 11/6/19 including emergency transportation and staffing plans.
Throat relief spray stored in the bathroom of resident #10 had an expiration date of 2016 and was removed on 11/6/19.
The home's procedures for safe use of medications and medical equipment did not include a process to investigate and account for missing medications and medication errors.
Report Facts
Residents Served: 71
Current Hospice Residents: 2
Staff Total Daily: 75
Staff Waking: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lawrence D. Marsteller | Administrator | Named in multiple plans of correction and signed all POCs |
Notice — Dec 13, 2018
Date: Dec 13, 2018
Visit Reason
This document serves as a renewal certificate and acknowledgment of the renewal application for the Personal Care Home license of Wesbury United Methodist Community. It also notifies the facility of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It is an administrative renewal notice confirming the license issuance and outlining future inspection requirements.
Report Facts
Inspection Report — Oct 16, 2018
Renewal
Date: Oct 16, 2018
Visit Reason
The inspection was a renewal visit conducted on October 16 and 17, 2018, to assess compliance with 55 Pa. Code Chapter 2600 for the Wesbury United Methodist Community Personal Care Home.
Findings
The inspection identified violations related to staff training in fire safety, medication administration documentation, and preadmission screening documentation. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (3)
55 Pa.Code §2600.65(g) Ancillary staff person A did not receive required fire safety training by a certified fire safety expert or trained staff during the inspection period.
55 Pa.Code 2600.187(a) Resident #1's medication record did not reflect the correct dosage change for Artificial Tears eye drops due to a national shortage, causing a discrepancy in administration documentation.
55 Pa.Code 2600.224(a) The preadmission screening for resident #2 did not indicate the resident's level of supervision needed or mobility needs.
Report Facts
Number of Residents Served: 63
Total Daily Staff: 66
Waking Staff: 50
Number of Current Hospice Residents: 3
Number of Hospice Residents in past year: 6
Number of Residents 60 Years or Older: 63
Number of Residents with Intellectual Disability: 1
Number of Residents with a Mobility Need: 3
Number of Residents with a Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lawrence D. Marsteller | Administrator | Named as facility administrator and legal entity representative signing plans of correction. |
Inspection Report — Dec 15, 2017
Renewal
Date: Dec 15, 2017
Visit Reason
This document is a renewal license issued to Wesbury United Methodist Community to operate a Personal Care Home. The Department acknowledges receipt of the renewal application and notifies that an onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It serves as a license renewal certificate and notification of future inspection requirements.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline L. Rowe | Director | Signed the renewal notification letter. |
Inspection Report — Nov 16, 2017
Renewal
Date: Nov 16, 2017
Visit Reason
The inspection was conducted as an annual licensing inspection and renewal visit for the Wesbury United Methodist Community Personal Care Home.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including issues with carbon monoxide detectors, staff training, hot water temperatures, emergency phone postings, facility repairs, food storage, fire drills, medical evaluations, first aid kits, and medication administration records. Plans of correction were submitted and partially or fully implemented for each violation.
Citations (14)
The facility lacked carbon monoxide detectors installed within 15 feet of gas appliances and did not post influenza information as required by the Influenza Awareness Act.
A direct care staff person completed only 9 hours and 55 minutes of the required 12 hours of annual training for 2016.
Direct care staff persons did not receive required annual training on resident rights, falls and accident prevention, protective services, and fire safety.
Hot water temperatures in resident-accessible areas exceeded 120°F at multiple locations on the inspection date.
Emergency service telephone numbers were not posted near telephones with outside lines in bedroom 139/140.
Furniture and equipment were not in good repair; bathroom stall latches and locks were inoperable and a heating/cooling unit cover was unsecured.
Leaves covered exterior stairs and a landing outside an emergency exit door, posing a fall hazard.
Outdated, unlabeled, and undated food items were found in the freezer in the second floor kitchenette.
Stairways, hallways, doorways, and egress routes were obstructed by tables and chairs, and excessive force was needed to open an exit door.
Combustible and flammable materials were stored near heat sources in the basement.
Fire drills were not conducted at varied times and days as required, with multiple drills held at the same time of day.
Resident medical evaluations were not completed within required timeframes after admission.
The first aid kit in the transportation vehicle lacked a breathing shield and antiseptic.
Blood glucose readings for several residents were recorded incorrectly on medication administration records.
Report Facts
Number of Residents Served: 56
Number of Current Hospice Residents: 1
Hot Water Temperatures: 133.5
Annual Training Hours Completed: 9.92
Required Annual Training Hours: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lawrence D. Marsteller | Administrator | Named as legal entity representative and administrator signing plans of correction. |
| Courtney Barry | Department representative conducting the inspection. | |
| Karen Georgoulis | Department representative conducting the inspection. |
Inspection Report — Dec 7, 2016
Renewal
Date: Dec 7, 2016
Visit Reason
The document is a renewal application and license issuance for Wesbury United Methodist Community to operate a Personal Care Home. The Department will conduct an onsite inspection within the next twelve months as part of the renewal process.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Dec 6, 2016
Renewal
Date: Dec 6, 2016
Visit Reason
The inspection was an annual licensing inspection conducted as a renewal of the facility's license under 55 Pa.Code Ch. 2600 for Personal Care Homes.
Findings
The inspection found violations related to resident privacy, vaccination documentation for resident pets, furnace maintenance, and first aid kit equipment. Plans of correction were submitted and partially implemented for all violations.
Citations (4)
55 Pa.Code §2600.17 requires resident records to be confidential and not accessible to unauthorized persons. The resident privacy coding document was not removed prior to posting the complete violation report, exposing resident names.
55 Pa.Code §2600.109(b) requires current rabies vaccination certificates for cats and dogs. Two cats residing in the home had expired rabies vaccination certificates as of 02/27/15.
55 Pa.Code §2600.126(a) requires annual inspection of furnaces by a professional or trained maintenance staff. The furnace in the pump room had not been inspected within the last year.
55 Pa.Code §2600.171(b)(5) requires first aid kits in transportation vehicles to include an operable thermometer. The first aid kit in the 2007 Ford vehicle lacked an operable thermometer, and the thermometer's battery was dead.
Report Facts
Number of Residents Served: 56
Total Daily Staff: 56
Waking Staff: 42
Number of Hospice Residents in past year: 2
Number of Residents 60 Years or Older: 56
Number of Residents with Intellectual Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lawrence D. Marsteller | Administrator | Named in plan of correction signatures and responsibility for violations |
Inspection Report — Feb 4, 2016
Renewal
Date: Feb 4, 2016
Visit Reason
The inspection was a licensing inspection conducted on February 4, 2016, related to renewal and provisional licensing of the Personal Care Home facility.
Findings
Violations of 55 Pa.Code Chapter 2600 were found, including issues with staff training, incomplete medical evaluations, untimely resident assessments, and incomplete support plans. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (5)
Regulation 2600.65(d) - A direct care staff person hired in January 2016 provided unsupervised ADL services without completing the required Department-approved direct care training and competency test by 2/3/16.
Regulation 2600.141(a)(2) - The medical evaluation dated 9/3/14 for resident #1 was blank in height, weight, pulse rate, blood pressure, and temperature fields.
Regulation 2600.141(b)(1) - Resident #1 did not have a medical evaluation completed at least annually; the most recent was on 9/3/14.
Regulation 2600.226(c) - Resident #1's most recent assessment was completed on 12/17/14, which was not timely.
Regulation 2600.227(d) - Support plans for residents #2, #3, and #4 indicated they were not able to evacuate independently, but assessments showed they were mobile and could evacuate independently with limited or no assistance.
Report Facts
Number of Residents Served: 64
Total Daily Staff: 64
Walking Staff: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lawrence D. Marsteller | Administrator | Named as legal entity representative signing plans of correction |
| Courtney Barry | On-site inspector for the inspection | |
| Cliff Hultquist | On-site inspector for the inspection |
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