20 Reports
Inspection Report — Apr 9, 2026
Complaint Investigation
Date: Apr 9, 2026
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations following a complaint.
Complaint Details
The visit was complaint-related as indicated by the inspection information. The plan of correction was accepted and fully implemented by 05/12/2026.
Findings
The inspection found violations related to medication security and resident record confidentiality, including unlocked and unattended medication containers accessible in a common area. The facility implemented corrective actions and re-education to address these issues.
Citations (2)
Record Confidentiality: Medication containers with resident names and prescriptions were found unlocked and unattended in a common area, violating confidentiality requirements.
Meds and Syringes Locked: Prescription medications and syringes were left unsecured and accessible atop a medication cart in the library.
Report Facts
Residents Served: 32
Current Hospice Residents: 7
Total Daily Staff: 43
Waking Staff: 32
Inspection Report — Dec 29, 2025
Renewal
Date: Dec 29, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit for renewal and complaint reasons on 12/29/2025 and 12/30/2025.
Findings
Multiple deficiencies were identified including unsafe mobility devices, improper storage of poisonous materials, unsanitary resident bathrooms, food safety violations, fire drill scheduling issues, medication management errors, incomplete training records, and incomplete resident support plans. Plans of correction were accepted and implemented by early March 2026.
Citations (12)
81b: Mobility devices affixed to resident beds were loose, moving 6 to 12 inches when pressure was applied, posing a safety hazard.
82a: An unlabeled spray bottle containing a blue liquid was found in a housekeeping cart; the administrator could not identify the liquid.
85a: Resident bathroom had a strong odor of urine with urine dripping from the toilet seat and feces present on the shower chair.
103c: Uncovered containers of pre-prepped salad toppings were stored in the walk-in refrigerator, risking contamination.
103d: A 5 lb. chub of ground beef was stored in a bin on the floor of the walk-in freezer, violating food storage requirements.
132e: Fire drills during sleeping hours were not conducted every six months as required.
183d: Discontinued medications were present in the medication cart and not removed timely.
185a: Medications prescribed as needed were not available in the home and blood glucose checks were not properly documented or administered.
187d: Medication administration errors occurred, including missed doses and failure to follow prescriber orders.
190c: Medication administration training records for staff members did not include completed initial summary and qualification user reports.
225c: Resident assessment was not updated to reflect a physician's order for no added sodium diet despite the resident being on a regular diet with thin liquids.
227d: Resident support plan did not document the specific need, risks, or safe use instructions for a Halo Safety Ring device used by the resident.
Report Facts
Residents Served: 30
Total Daily Staff: 37
Waking Staff: 28
Current Hospice Residents: 6
Residents Age 60 or Older: 30
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 7
Inspection Report — May 13, 2025
Complaint Investigation
Date: May 13, 2025
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 05/13/2025.
Complaint Details
The inspection was triggered by a complaint and was unannounced. The plan of correction was fully implemented as of 05/13/2025.
Findings
The inspection identified multiple deficiencies including expired CPR certification of staff, unlabeled bar soap in shared bathrooms, medication administration errors, failure to follow prescriber's orders, and incomplete resident assessments reflecting changes in physical and behavioral conditions.
Citations (5)
Staff member performed CPR with expired certification until recertified in January 2025.
Unlabeled green bar soap found in shared bathroom, violating soap dispenser requirements.
Medication administration record showed incorrect frequency of medication administration compared to physician's order.
Medication was not administered as prescribed by the physician, including incorrect timing and dosage.
Resident assessments were not updated to reflect significant changes in mobility, physical assistance needs, and behavioral issues.
Report Facts
Residents Served: 35
Current Hospice Residents: 5
Residents 60 Years or Older: 35
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 16
Total Daily Staff: 51
Waking Staff: 38
Number of Staff Trained in CPR/First Aid: 8
Deficiencies Cited: 5
Inspection Report — Nov 21, 2024
Complaint Investigation
Date: Nov 21, 2024
Visit Reason
The inspection was conducted as a complaint investigation following a report of incidents at the facility.
Complaint Details
Complaint investigation due to a report that a resident was punching and biting a staff person. The incident was not reported to the Department as required.
Findings
The facility failed to report an incident involving a resident assaulting a staff member, and staff administered medications without proper certification and documentation. The submitted plan of correction was accepted and fully implemented.
Citations (3)
Failure to report an incident of a resident punching and biting a staff person to the Department within 24 hours.
Staff administered prescription medications without completing the required medication administration training.
Medication administration records were inaccurately documented by staff who did not administer the medications.
Report Facts
Residents served: 33
Total daily staff: 37
Waking staff: 28
Current hospice residents: 3
Residents 60 years or older: 33
Residents with mobility need: 4
Inspection Report — Feb 8, 2024
Complaint Investigation
Date: Feb 8, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 02/08/2024.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and no follow-up was required.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Residents Served: 29
Current Hospice Residents: 3
Resident Support Staff: 35
Waking Staff: 26
Residents Age 60 or Older: 29
Residents with Mobility Need: 6
Inspection Report — Jun 22, 2023
Renewal
Date: Jun 22, 2023
Visit Reason
The inspection was conducted as a renewal visit to review compliance and verify the submitted plan of correction was fully implemented.
Findings
The inspection identified multiple deficiencies related to staff orientation and training, sanitary conditions, surface cleanliness, and medication administration course completion. Plans of correction were accepted and implemented with ongoing quality assurance measures.
Citations (5)
Staff Member A did not receive required fire safety and emergency preparedness orientation on the first work day.
Staff Member A did not complete required training on resident rights, abuse reporting, and emergency medical plan within 40 scheduled working hours.
Resident #1's glucometer was used to check Resident #2's blood glucose levels, violating sanitary conditions.
Mechanical ventilation systems in bathrooms of resident rooms #203 and #205 were covered in thick dust, potentially preventing proper ventilation.
Staff Member A had not successfully completed the Department-approved medication administration course and required observations; Staff Member C had not completed an annual practicum since 9/11/2020.
Report Facts
Residents Served: 31
Current Hospice Residents: 2
Total Daily Staff: 35
Waking Staff: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandon Laboy | Resident Care Director | Received re-education on glucometer error and medication administration violations |
| Chris Moyer | Maintenance Assistant | Cleaned ventilation systems in resident rooms #203 and #205 |
Inspection Report — Dec 2, 2022
Complaint Investigation
Date: Dec 2, 2022
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility.
Complaint Details
The inspection was complaint-related, but no deficiencies or regulatory citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 28
Current Hospice Residents: 2
Resident Support Staff: 0
Total Daily Staff: 37
Waking Staff: 28
Residents Age 60 or Older: 28
Residents with Mobility Need: 9
Residents with Physical Disability: 1
Inspection Report — Jun 7, 2022
Renewal
Date: Jun 7, 2022
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements for Traditions of Hershey.
Findings
The inspection identified several deficiencies including expired carbon monoxide detector battery, unqualified direct care staff, uncovered trash receptacles, unlocked medications, unlabeled resident medications, missed medication doses, and delayed resident initial assessment. All violations were corrected during or shortly after the survey with plans of correction implemented.
Citations (7)
Battery in the carbon monoxide detector in the kitchen was not replaced within one year.
Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Uncovered, unattended trash can found in the bathroom of a resident's room.
A container of Bio Freeze roll-on was found unlocked, unattended, and accessible beside the bed in a resident's room.
OTC medications in the treatment cart were not labeled with the resident's name.
Medication Administration Record showed that the morning dose of a prescribed medication was not given on multiple days.
Initial assessment and support plan for a resident were not completed within the required 15 days of admission.
Report Facts
Residents Served: 30
Staffing Hours: 39
Waking Staff: 29
Current Hospice Residents: 1
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 9
Residents with Physical Disability: 1
Notice — Oct 22, 2021
Date: Oct 22, 2021
Visit Reason
The document serves as a renewal license notification for the Personal Care Home 'Traditions of Hershey' following receipt of the renewal application dated October 21, 2021. It also advises 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 and states that enforcement action will be taken if noncompliance is found during future inspections.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal license notification letter |
Notice — Jan 22, 2021
Date: Jan 22, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for the Personal Care Home 'Traditions of Hershey' following receipt of the renewal application dated November 4, 2020.
Findings
No inspection findings are reported; the document confirms that an onsite inspection will be conducted within the next twelve months as required by regulation.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
Inspection Report — Mar 6, 2020
Renewal
Date: Mar 6, 2020
Visit Reason
This document is a renewal license issued to Traditions of Hershey for operating a Personal Care Home. The Department received a renewal application and will conduct an onsite inspection within the next twelve months as required by Pennsylvania regulations.
Findings
No inspection findings are reported in this document. It serves as a license renewal certificate and notification of future inspection requirements.
Inspection Report — Nov 18, 2019
Renewal
Date: Nov 18, 2019
Visit Reason
The inspection was a full, unannounced renewal inspection of Traditions of Hershey conducted by the Pennsylvania Department of Human Services on November 18, 2019.
Findings
The inspection identified several deficiencies related to hospice care fire drill evacuations, emergency management agency submissions, medication storage, and blood sugar reading documentation. A plan of correction was submitted and determined to be fully implemented as of March 6, 2020.
Citations (5)
29a SOPb1 Hospice Care: Resident #1 was not evacuated during fire drills on 5/28/19, 6/12/19, and 7/30/19, and there was no written physician certification that the resident was actively dying to justify non-evacuation.
29a SOPb5ii Hospice Care: Staff did not reasonably simulate the effort required to move Resident #1 during fire drills on 5/28/19, 6/1/19, and 7/30/19 to the nearest unblocked exit or fire safe area.
107d Procedure Emergency Management Agency Submission: The home's written emergency procedures were not submitted to the local emergency management agency for 2018.
183e Storing Medications: Two loose pills were found in the home's medication cart during the annual survey on 11/18/19.
185a Implement Storage Procedures: Blood sugar readings in residents' glucometers did not match readings documented on medication administration records for Resident #2 on 11/5/19 and 11/6/19.
Report Facts
Residents Served: 33
Resident Support Staff: 0
Total Daily Staff: 41
Waking Staff: 31
Have Mobility Need: 8
Are 60 Years of Age or Older: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Lapinsky | Administrator | Named in relation to plan of correction and signature on violation report |
| Kellie Cargile | Department representative present during inspection | |
| Mike Showers | Department representative present during inspection |
Inspection Report — Jan 9, 2019
Renewal
Date: Jan 9, 2019
Visit Reason
The inspection was a renewal inspection conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa.Code Chapter 2600 for Traditions of Hershey.
Findings
The inspection found violations related to fire safety training, combustible materials accessibility, and resident evacuation during fire drills. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (3)
55 Pa.Code 2600.65(g) - Direct care staff members A and B did not receive fire safety training by a fire safety expert in 2018.
55 Pa.Code 2600.125(b) - Two full 15-pound propane tanks were accessible to residents by the grill at the rear patio of the facility.
55 Pa.Code 2600.132(h) - All residents did not evacuate during multiple fire drills conducted between 2/15/2018 and 9/20/2018.
Report Facts
Number of Residents Served: 31
Total Daily Staff: 35
Waking Staff: 26
Number of Current Hospice Residents: 2
Number of Hospice Residents in past year: 13
Number of Residents Age 60 or Older: 31
Number of Residents with Mental Illness: 2
Number of Residents with Mobility Need: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah K. McConnell | Administrator | Named as Administrator and Legal Entity Representative signing violation reports and plans of correction. |
Notice — Dec 13, 2018
Date: Dec 13, 2018
Visit Reason
The document is a renewal notification and license issuance letter for the Personal Care Home 'Traditions of Hershey' following receipt of a renewal application.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license and outlines the requirement for an annual onsite inspection within the next twelve months.
Report Facts
Inspection Report — Jan 18, 2018
Annual Inspection
Date: Jan 18, 2018
Visit Reason
The inspection was conducted as an annual licensing inspection by the Department of Human Services.
Findings
The facility was found to be in compliance with 55 Pa.Code Chapter 2600 relating to Personal Care Homes.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline L. Rowe | Director | Signed the letter confirming the inspection results. |
Notice — Oct 16, 2017
Date: Oct 16, 2017
Visit Reason
This document serves as a renewal notification and license issuance for the Personal Care Home 'Traditions of Hershey' following receipt of the renewal application dated October 16, 2017.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license and outlines the requirement for an annual onsite inspection within the next twelve months.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline L. Rowe | Director | Signed the renewal notification letter. |
Inspection Report — Feb 2, 2017
Renewal
Date: Feb 2, 2017
Visit Reason
The inspection was an annual licensing inspection conducted as a renewal of the facility's license.
Findings
The inspection found violations related to resident refunds, criminal background checks, and heat source safety. All violations were corrected by the dates specified in the plan of correction.
Citations (3)
55 Pa.Code §2600.28(e): The facility did not issue a refund for care charges for a resident under 60 years of age who passed away, violating the Elder Care Payment Restitution Act.
55 Pa.Code §2600.51: A Pennsylvania State Police criminal history background check was not completed for a staff member prior to hiring.
55 Pa.Code §2600.84: The metal strip above the gas fireplace reached 156.3°F without a protective guard, posing a risk to residents.
Report Facts
Number of Residents Served: 30
Total Daily Staff: 31
Walking Staff: 23
Refund Amount: 88.76
Number of Days Refunded: 4
Temperature: 156.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeremy Keiter | Administrator | Named as legal entity representative and administrator involved in plan of correction. |
| Kelly Comstock | Department representative on-site during inspection. | |
| Cybill Bomberger | Department representative on-site during inspection. |
Notice — Oct 19, 2016
Date: Oct 19, 2016
Visit Reason
This document serves as a renewal notification and license issuance for the Personal Care Home 'Traditions of Hershey' following receipt of the renewal application dated October 18, 2016.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license and states that an onsite inspection will be conducted within the next twelve months as required by regulation.
Report Facts
Notice — May 27, 2016
Date: May 27, 2016
Visit Reason
This document serves to notify the facility of the granted waiver for certain Pennsylvania Code requirements related to admission, resident medical evaluation, and preadmission screening for Traditions of Hershey personal care home.
Findings
The waiver is granted under specified conditions including use of alternative medical evaluation and screening forms. The Department will review the waiver annually during inspections to ensure compliance.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tara Pride | Director of Regulatory Implementation | Signed the waiver approval letter. |
Inspection Report — Jan 15, 2016
Original Licensing
Date: Jan 15, 2016
Visit Reason
The inspection was conducted as a licensing inspection for a new legal entity operating the Personal Care Home facility Traditions of Hershey.
Findings
The facility was found to be in substantial compliance with the regulations set forth in 55 Pa.Code Chapter 2600 relating to Personal Care Homes. The licensing inspector was unable to complete a full inspection due to the newness of the legal entity.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matthew J. Jones | Director | Signed the licensing inspection letter |
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