Deficiencies per Year
8
6
4
2
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Renewal
Census: 104
Capacity: 180
Deficiencies: 8
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devices, incomplete fire drill records, omissions in annual medical evaluations, unlocked medications and syringes, outdated medications in the medication cart, incorrect medication labeling, and incomplete resident support plans related to medical and dental care.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.
Deficiencies (8)
| Description |
|---|
| 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
License Capacity: 180
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
Inspection Report
Renewal
Census: 108
Capacity: 180
Deficiencies: 1
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.
Deficiencies (1)
| Description |
|---|
| Resident's medication label did not reflect the updated insulin dosage as of 08/14/2024. |
Report Facts
License Capacity: 180
Residents Served: 108
Current Hospice Residents: 3
Total Daily Staff: 108
Waking Staff: 81
Inspection Report
Complaint Investigation
Census: 101
Capacity: 180
Deficiencies: 0
Mar 5, 2024
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection on 03/05/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-driven; no deficiencies were found and no follow-up was required.
Report Facts
Total Daily Staff: 101
Waking Staff: 76
License Capacity: 180
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
Renewal
Census: 86
Capacity: 180
Deficiencies: 1
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.
Deficiencies (1)
| Description |
|---|
| 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
License Capacity: 180
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
| Name | Title | Context |
|---|---|---|
| Darrel Jefferys | Director of Maintenance | Named in plan of correction for adding emergency phone numbers |
Notice
Capacity: 180
Deficiencies: 0
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
Total licensed capacity: 180
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal license approval letter. |
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