The Pennsylvania Department of Health found that the Meadows Psychiatric Center failed to ensure that patients received care in a safe setting. A patient was woken up at approximately 3 AM by their roommate sitting on their bed and rubbing their back. An employee said, “This patient was very scared.” The facility did not record the incident in the patient’s medical record or update the perpetrator’s treatment plan to reflect Boundary Precautions. Additionally, the facility’s nursing services were found deficient related to the documentation of responsibilities for patient care. One patient’s medical record included a series of “Suicide Risk Assessment Tool” forms which included four questions about the presence of suicidal ideation, suicidal behaviors, suicide plan and suicidal intent, noting “If any answer to questions 1-4 is yes, contact physician.” Some of the patient’s records indicated “yes” answers to the questions but no documentation of physician contact and/or intervention. As a result of these violations, the facility had to submit plans of correction to address its cited deficiencies and deficient policies and procedures.