Inspection Reports for
Country Meadows

PA, 17050

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25 Reports

2017–2026

Inspection Report — Apr 29, 2026

Follow-Up
Date: Apr 29, 2026

Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.

Findings
The facility was found to have fully implemented the plan of correction related to timely reporting of suspected resident abuse. The report details repeated violations involving delayed reporting of abuse incidents and corrective actions including staff suspension, termination, and training on timely reporting.

Citations (2)
15a - Resident Abuse Report: The residence failed to immediately report suspected abuse incidents involving Staff Member B being rough with residents and throwing them into bed. The incidents were reported late to the Area Agency on Aging.
16c - Written Incident Report: The home did not report abuse incidents to the Department’s personal care home regional office or complaint hotline within 24 hours as required by regulation.
Report Facts
Residents Served: 105 Total Daily Staff: 153 Waking Staff: 115 Current Residents in Hospice: 7 Residents with Mobility Need: 48 Residents Age 60 or Older: 1

Notice — Apr 9, 2026

Date: Apr 9, 2026

Visit Reason
This letter responds to a request from the facility to use the Safely You Falls Management Program to support fall detection and management for individuals with cognitive impairment.

Findings
The Department reviewed the submitted information and determined that the informed consent process includes voluntary participation and the right to discontinue camera use. The facility's practices satisfy regulatory requirements regarding residents' right to privacy.

Employees mentioned
NameTitleContext
Theresa HartmanDirectorSigned the letter responding to the facility's request regarding the Safely You Falls Management Program.

Inspection Report — Feb 19, 2026

Follow-Up
Date: Feb 19, 2026

Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.

Findings
The facility was found to have multiple deficiencies related to resident abuse reporting, incident reporting, record confidentiality, activities of daily living assistance, abuse, and medication security. The submitted plan of correction was determined to be fully implemented as of the follow-up inspection date.

Citations (6)
15a Resident Abuse Report: The facility failed to immediately report suspected resident abuse to the local area agency on aging as required by regulations.
16c Written Incident Report: The facility did not report an incident involving staff throwing a resident into bed resulting in injury to the Department as required within 24 hours.
17 Record Confidentiality: Resident personal information was left unlocked and accessible on an open laptop on a medication cart near the dining room.
23a Activities of Daily Living Assistance: Staff failed to provide required physical assistance to a resident for toileting, instructing the resident to "pee the bed."
42b Abuse: Staff physically abused a resident by throwing them into bed causing injury and exhibited neglect by refusing to assist with toileting and rushing care.
183b Meds and Syringes Locked: Medications were found unlocked, unattended, and accessible on a medication cart near the dining room.
Report Facts
Residents Served: 104 Current Hospice Residents: 4 Residents Age 60 or Older: 103 Residents with Mobility Need: 43 Residents with Physical Disability: 2 Total Daily Staff: 147 Waking Staff: 110

Notice — Jan 2, 2026

Date: Jan 2, 2026

Visit Reason
This document serves to notify the facility that a waiver request to 55 Pa.Code § 2600.54(a)(2) regarding direct care staff qualifications has been granted.

Findings
The waiver allows a specific employee to serve as direct care staff despite not meeting the usual high school diploma, GED, or nurse aide registry requirements, based on education received outside the United States. The waiver is subject to annual review during inspections and compliance with specified conditions.

Notice — Oct 27, 2025

Date: Oct 27, 2025

Visit Reason
This document serves to notify the facility that a waiver request to 55 Pa.Code § 2600.54(a)(2) regarding direct care staff qualifications has been granted.

Findings
The waiver allows a specific employee to serve as direct care staff despite not meeting the usual high school diploma, GED, or nurse aide registry requirements, based on education obtained outside the United States. The waiver is subject to annual review during the facility's annual inspection and requires documentation to be maintained in personnel files.

Employees mentioned
NameTitleContext
Theresa HartmanBureau Director, Human Services LicensingSigned the waiver approval letter.

Inspection Report — Aug 26, 2025

Renewal
Date: Aug 26, 2025

Visit Reason
The inspection was conducted as a renewal inspection of the facility, Country Meadows of West Shore, to review compliance with licensing requirements.

Findings
The inspection found multiple deficiencies including failure to post waivers, improper installation of bedside mobility devices, incomplete fire drill records, omissions in annual medical evaluations, unlocked medications and syringes, outdated medications in the medication cart, incorrect medication labeling, and incomplete resident support plans related to medical and dental care. Plans of correction were accepted and implemented with follow-up monitoring scheduled.

Citations (8)
Waivers for staff education were not posted in the home as required.
A bedside mobility device was not installed on resident #1's bed as ordered.
Fire drill records did not include the total number of residents evacuated, only those evacuated from the fire area.
Annual medical evaluations for residents #3, #4, #5, and #6 were missing height and other required information.
Unlocked and unattended medications (Neosporin ointment and Balmex diaper rash cream) were accessible in residents' rooms where residents were not assessed to self-administer.
Discontinued medications (Tramadol and Insulin Aspart) were found in the medication cart.
Medication label for resident #8's insulin had incorrect dosage instructions.
Resident support plans for multiple residents using bedside mobility devices did not include required specific information about device use, risks, and safety.
Report Facts
Residents Served: 104 Staffing Hours: 146 Waking Staff: 110 Current Hospice Residents: 4 Residents 60 Years or Older: 103 Residents with Mobility Need: 42 Fire Drill Residents Present: 101 Residents Evacuated: 35 Fire Drill Residents Present: 98 Residents Evacuated: 35 Fire Drill Residents Present: 103 Residents Evacuated: 23 Fire Drill Residents Present: 105 Residents Evacuated: 38

Notice — Jul 22, 2025

Date: Jul 22, 2025

Visit Reason
This document serves to notify the facility that a waiver request to waive the high school diploma, GED, or active registry status requirement for a direct care staff person has been granted.

Findings
The waiver is granted under specific conditions including documentation of education and training to be kept on file and subject to annual review during inspections. Noncompliance may result in termination of the waiver or other licensing actions.

Employees mentioned
NameTitleContext
Theresa HartmanBureau Director, Human Services LicensingSigned the waiver approval letter.

Notice — Apr 16, 2025

Date: Apr 16, 2025

Visit Reason
The document serves to notify the facility that a waiver request to 55 Pa.Code § 2600.54(a)(2) regarding direct care staff qualifications has been granted.

Findings
The waiver allows a specified employee to serve as direct care staff based on education equivalency determined by an accredited evaluator. The waiver is subject to annual review during the facility's annual inspection and compliance with specified conditions.

Employees mentioned
NameTitleContext
Theresa HartmanBureau Director, Human Services LicensingSigned the waiver approval letter.

Notice — Jan 30, 2025

Date: Jan 30, 2025

Visit Reason
The document serves to grant a waiver for a direct care staff person at Country Meadows of West Shore who received their education outside of the United States, waiving the requirement for a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.

Findings
The waiver is granted under specific conditions including documentation of a Bachelor of Science in Nursing degree and maintenance of educational qualifications in personnel files. The Department will review this waiver annually during inspections to ensure compliance.

Notice — Dec 17, 2024

Date: Dec 17, 2024

Visit Reason
The document serves to notify the facility that a waiver request to 55 Pa.Code § 2600.54(a)(2) regarding direct care staff qualifications has been granted.

Findings
The waiver allows an employee without a high school diploma or GED to serve as direct care staff based on education received outside the United States, subject to conditions and annual review.

Employees mentioned
NameTitleContext
Theresa HartmanBureau Director, Human Services LicensingSigned the waiver approval letter.

Notice — Dec 16, 2024

Date: Dec 16, 2024

Visit Reason
The document serves to grant a waiver for a direct care staff member at Country Meadows of West Shore who received their education outside the United States, waiving the requirement for a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.

Findings
The waiver is granted under specific conditions including documentation of the staff member's Bachelor of Science in Nursing degree and requires annual review during the facility's annual inspection to ensure compliance.

Inspection Report — Aug 13, 2024

Renewal
Date: Aug 13, 2024

Visit Reason
The inspection was conducted as a renewal inspection of the facility's license, including a full unannounced review from 08/13/2024 to 08/15/2024.

Findings
The submitted plan of correction related to medication labeling was fully implemented and compliance was maintained. A specific deficiency was found regarding an outdated pharmacy label on a resident's medication, which was promptly corrected.

Citations (1)
Resident's medication label did not reflect the updated insulin dosage as of 08/14/2024.
Report Facts
Residents Served: 108 Current Hospice Residents: 3 Total Daily Staff: 108 Waking Staff: 81

Notice — Jun 12, 2024

Date: Jun 12, 2024

Visit Reason
The document serves to notify the facility that a waiver request to 55 Pa.Code § 2600.54(a)(2) regarding direct care staff educational qualifications has been granted.

Findings
The waiver is granted under specified conditions allowing a direct care staff member educated outside the United States to serve based on submitted documentation. The Department will review this waiver annually during inspections to ensure compliance.

Employees mentioned
NameTitleContext
Theresa HartmanBureau Director, Human Services LicensingSigned the waiver approval letter.

Inspection Report — Mar 5, 2024

Complaint Investigation
Date: Mar 5, 2024

Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection on 03/05/2024.

Complaint Details
The inspection was complaint-driven; no deficiencies were found and no follow-up was required.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.

Report Facts
Total Daily Staff: 101 Waking Staff: 76 Residents Served: 101 Current Residents in Hospice: 0 Residents 60 Years or Older: 101 Residents Receiving Supplemental Security Income: 0 Residents Diagnosed with Mental Illness: 0 Residents Diagnosed with Intellectual Disability: 0 Residents with Mobility Need: 0 Residents with Physical Disability: 0

Inspection Report — Dec 1, 2021

Renewal
Date: Dec 1, 2021

Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.

Findings
The submitted plan of correction was determined to be fully implemented following the inspection. A deficiency was noted regarding the absence of emergency telephone numbers by resident phones, which was corrected by adding phone numbers and establishing a monthly check process.

Citations (1)
No emergency telephone numbers that include the nearest hospital and fire department were posted on or by the telephones in the bedrooms of Resident 1, 2, and 3.
Report Facts
Residents Served: 86 Current Hospice Residents: 4 Total Daily Staff: 87 Waking Staff: 65 Residents Age 60 or Older: 85 Residents with Mobility Need: 1 Residents with Physical Disability: 1

Employees mentioned
NameTitleContext
Darrel JefferysDirector of MaintenanceNamed in plan of correction for adding emergency phone numbers

Notice — Jul 30, 2021

Date: Jul 30, 2021

Visit Reason
The document serves as a renewal license approval and notification that the Department will conduct an annual inspection within the next twelve months as required by regulation.

Findings
The Department issued a regular license in response to the renewal application and advised that an onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.

Report Facts

Employees mentioned
NameTitleContext
Jamie L. BuchenauerDeputy Secretary, Office of Long-term LivingSigned the renewal license approval letter.

Inspection Report — Jul 17, 2019

Annual Inspection
Date: Jul 17, 2019

Visit Reason
The inspection was conducted as the annual licensing inspection by the Department’s Bureau of Human Services Licensing on July 17 and July 18, 2019.

Findings
The facility was found to be in compliance with 55 Pa.Code Chapter 2600 relating to Personal Care Homes.

Notice — May 10, 2019

Date: May 10, 2019

Visit Reason
This document serves as a renewal notice and license issuance for Country Meadows of West Shore LLC to operate a Personal Care Home. It informs the recipient of the renewal application receipt and 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 license renewal notice with an enclosed certificate of occupancy.

Report Facts

Notice — Jan 31, 2019

Date: Jan 31, 2019

Visit Reason
The document communicates the Department's determination that a waiver for direct care staff qualifications is not needed for Christ's Home Retirement Community.

Findings
The Department reviewed submitted documentation and determined that the educational requirements for a direct care staff person are met, recommending the facility keep copies of the documentation in personnel files.

Employees mentioned
NameTitleContext
Jill KachmarRegulatory Licensing ManagerSigned the waiver determination letter.

Notice — Jan 23, 2019

Date: Jan 23, 2019

Visit Reason
The document communicates the Department of Human Services' determination that a waiver for direct care staff qualifications is not needed for Country Meadows of West Shore.

Findings
The Department reviewed submitted documentation and determined the staff member meets the educational requirements to serve as a direct care staff person. The Department recommends keeping copies of the documentation in personnel files.

Notice — Oct 11, 2018

Date: Oct 11, 2018

Visit Reason
The document serves to notify that the previously issued consolidated Certificate of Compliance for Country Meadows of West Shore was issued in error and is being rescinded, reinstating separate Certificates of Compliance for each facility with their original capacities and expiration dates.

Findings
A review found that the facilities operate independently with separate services and management, invalidating the consolidated certificate. The original certificates with separate capacities are reinstated and the consolidated certificate is rescinded.

Employees mentioned
NameTitleContext
Jacqueline L. RoweDirectorSigned the letter rescinding the consolidated Certificate of Compliance.

Inspection Report — Jul 23, 2018

Annual Inspection
Date: Jul 23, 2018

Visit Reason
The inspection was conducted as part of the Department's Bureau of Human Services Licensing annual inspection to assess compliance with 55 Pa.Code Chapter 2600 relating to Personal Care Homes.

Findings
The facility was found to be in compliance with applicable laws and regulations. The licensed capacity was revised due to the consolidation of licenses and adjustment of physical space use.

Inspection Report — May 15, 2018

Renewal
Date: May 15, 2018

Visit Reason
The document is a renewal application and license issuance for Country Meadows of West Shore Personal Care Home. The Department notifies that an onsite inspection will be conducted within the next twelve months as part of the annual inspection requirement.

Findings
No inspection findings are reported in this document. It serves as a license renewal confirmation and notification of upcoming inspection requirements.

Report Facts

Notice — Aug 28, 2017

Date: Aug 28, 2017

Visit Reason
This document serves as a notice of a new license issuance for Country Meadows of West Shore, LLC, following a change in the legal entity name.

Findings
The document confirms the issuance of a license for the facility to operate as a Personal Care Home with a maximum capacity of 180 persons.

Report Facts

Notice — June 23, 2020

Date: June 23, 2020

Visit Reason
This document serves as a renewal notification and certificate of compliance for the Personal Care Home license at Country Meadows of West Shore. It informs the facility that an annual onsite inspection will be conducted within the next twelve months as required by regulation.

Findings
No inspection findings are reported in this document. It confirms issuance of a regular license following the renewal application.

Report Facts

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