25 Reports
Inspection Report — Feb 11, 2026
Follow-Up
Date: Feb 11, 2026
Visit Reason
The inspection was a partial, unannounced follow-up visit to verify the implementation of a previously submitted plan of correction related to an incident.
Findings
The facility was found to have fully implemented the plan of correction addressing confidentiality breaches, abuse incidents, snow removal, and prohibited manual restraint use. Corrective actions included staff re-education, audits, and procedural changes.
Citations (4)
17 - Record Confidentiality: A laptop on the medication cart was left unattended displaying multiple residents' information, accessible to anyone in the area.
42b - Abuse: Staff Member A held a resident's wrists during a behavioral incident and made inappropriate statements, resulting in redness on the resident's wrists.
100b - Removal Snow/Obstructions: Approximately 3–4 inches of snow accumulated on a sidewalk outside the Pathways Unit, obstructing access.
202 - Prohibitions: Manual restraint was used when Staff Member A held the resident's wrists during care, which is prohibited.
Report Facts
Residents Served: 101
Secured Dementia Care Unit Residents Served: 34
Hospice Current Residents: 7
Residents Age 60 or Older: 134
Residents with Mobility Need: 42
Residents with Intellectual Disability: 1
Residents with Physical Disability: 4
Inspection Report — Dec 23, 2025
Date: Dec 23, 2025
Visit Reason
The inspection was a partial, unannounced licensing inspection conducted as an incident and interim review of the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 134
Secured Dementia Care Unit Residents Served: 35
Current Hospice Residents: 8
Residents Age 60 or Older: 133
Residents with Mobility Need: 43
Residents Diagnosed with Intellectual Disability: 1
Residents Diagnosed with Physical Disability: 4
Inspection Report — Oct 22, 2025
Complaint Investigation
Date: Oct 22, 2025
Visit Reason
The inspection was conducted as a complaint investigation and incident review following allegations of resident abuse and failure to report incidents at Country Meadows of Hershey.
Complaint Details
The visit was complaint-related due to allegations of resident abuse and failure to report incidents. The complaint was substantiated with multiple violations found regarding abuse reporting, incident documentation, and resident care.
Findings
The facility failed to immediately report suspected resident abuse and other incidents to the appropriate authorities. Multiple violations related to resident abuse, incident reporting, secure medical care, additional assessments, and support plan documentation were identified. The facility submitted plans of correction which were accepted and implemented.
Citations (6)
Reg 15a: The home failed to immediately report suspected abuse of a resident involving non-consensual physical contact to the local Area Agency on Aging.
Reg 16c: The home did not report incidents of unresponsiveness and emergency room transfers to the Department within 24 hours as required.
Reg 42b: Resident exhibited sexually inappropriate behaviors and physical abuse incidents occurred, including punching resulting in injury, violating abuse prohibitions.
Reg 142a: The home failed to document the resident's need for medical care and did not complete ordered 15-minute supervision checks, despite resident's increased behaviors and hospitalizations.
Reg 225c: The resident's assessment was not updated timely to reflect increased supervision needs related to documented sexually inappropriate behaviors.
Reg 227d: The resident's support plan did not reflect the requirement that at least two staff provide care for safety due to inappropriate behaviors.
Report Facts
Residents Served: 137
Secured Dementia Care Unit Residents Served: 34
Current Hospice Residents: 6
Resident Age 60 or Older: 137
Residents with Mobility Need: 46
Residents with Intellectual Disability: 1
Residents with Physical Disability: 3
Notice — Sep 4, 2025
Date: Sep 4, 2025
Visit Reason
Response to a facility request 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, the right to discontinue use of cameras, and notification of resident rights, satisfying regulatory requirements around privacy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Director, Bureau of Human Services Licensing | Signed the letter responding to the facility's request regarding the Safely You Falls Management Program. |
Notice — Jun 17, 2025
Date: Jun 17, 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 under specified conditions.
Findings
The waiver allows a direct care staff member without a high school diploma, GED, or active registry status to serve based on education obtained outside the United States, subject to documentation and annual review during inspections.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Notice — Sep 24, 2024
Date: Sep 24, 2024
Visit Reason
The document serves to notify the facility that a waiver request to waive the high school diploma or GED requirement for a direct care staff person has been granted due to education obtained outside the United States.
Findings
The waiver is granted under specific conditions including documentation of equivalent education and maintenance of records by the facility. The Department will review this waiver annually during inspections to ensure compliance.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Jul 10, 2024
Follow-Up
Date: Jul 10, 2024
Visit Reason
The inspection visit on 07/10/2024 was a partial, unannounced follow-up inspection triggered by a complaint and incident to verify the implementation of a submitted plan of correction.
Complaint Details
The inspection was complaint-related, triggered by allegations of resident abuse and incidents involving maladaptive behaviors requiring 1:1 staffing. The complaint was substantiated as deficiencies were identified and addressed.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing prior deficiencies related to resident abuse, medication labeling, medication administration documentation, and additional resident assessments. Continued compliance is required.
Citations (4)
Resident-to-resident abuse incidents in the secured dementia care unit were observed, including verbal and physical altercations, with inadequate staff intervention prior to the incident.
Pharmacy label for Resident #3's medication did not include current administration instructions, differing from physician's orders.
Medication Administration Record did not include initials of staff who administered a non-medicated cream to Resident #3 on 7/6/2024 at 8:00 PM.
Resident #1 and Resident #4's assessments and support plans did not reflect significant behavioral changes and did not address how behavioral needs would be met through staff supports.
Report Facts
Residents Served: 127
Secured Dementia Care Unit Residents Served: 32
Current Hospice Residents: 6
Residents Age 60 or Older: 126
Residents with Mobility Need: 33
Inspection Report — Apr 4, 2023
Renewal
Date: Apr 4, 2023
Visit Reason
The inspection was conducted as a renewal and incident review of the facility on 04/04/2023, 04/05/2023, 04/06/2023, and 04/07/2023.
Findings
The inspection found multiple deficiencies including insufficient CPR-trained staff during night shifts, inoperable bathroom exhaust fans, unsealed food storage, unlocked medications accessible to residents, loose pills in medication carts, missing medications, and incomplete medication administration documentation. Plans of correction were accepted and implemented by May 2023.
Citations (7)
Insufficient number of staff trained in CPR and first aid during night shifts on 3/25/23 and 3/26/23.
Bathrooms in bedrooms 213 and 214 lacked operable exhaust fans for ventilation.
Two large trays of meat sauce in the walk-in cooler were opened and unsealed.
Prescription medications, OTC medications, CAM and syringes were unlocked and accessible in Resident 1's bedroom.
Two loose pills were observed in the Connections medication cart.
Resident 2's prescribed medication was not available in the home on 4/5/23.
Resident 2's medication administration record did not include the initials of the staff person who administered medication on a specified date and time.
Report Facts
Residents Served: 137
Secured Dementia Care Unit Residents Served: 34
Current Hospice Residents: 11
Residents Age 60 or Older: 136
Residents with Mobility Need: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Responsible for ensuring CPR training compliance, medication storage, medication audits, and overall compliance with regulations. | |
| Assistant Director of Nursing | Assisted in training nightshift coworkers in CPR. | |
| Executive Director | Responsible for completing random audits to ensure CPR trained coworkers on nightshift. | |
| Director of Maintenance | Responsible for fixing bathroom exhaust fans and conducting audits to ensure operational status. | |
| Chef Manager | Covered meat sauce immediately upon discovery of unsealed food. | |
| Director of Dining Services | Responsible for educating culinary associates on proper food storage and conducting audits. | |
| Associate Executive Director | Locked apartment door immediately upon discovery of unlocked medications. | |
| Director of Nursing | Responsible for medication storage, medication audits, reordering medications, and ensuring documentation of medication administration. |
Inspection Report — Feb 8, 2023
Follow-Up
Date: Feb 8, 2023
Visit Reason
The inspection was conducted as a follow-up review of a previously submitted plan of correction related to an incident at the facility.
Findings
The facility was found to have fully implemented the submitted plan of correction regarding an unreported resident incident and a confidentiality breach involving resident records. Continued compliance was required.
Citations (2)
Failure to report an incident where resident #1 punched resident #2 to the Department within 24 hours.
A laptop computer containing personally identifiable information for 16 residents was found unlocked and unsupervised on a medication cart in a hallway.
Report Facts
Residents Served: 155
Secured Dementia Care Unit Residents Served: 36
Current Hospice Residents: 11
Residents Age 60 or Older: 154
Residents with Mobility Need: 48
Residents with Physical Disability: 1
Residents with Supplemental Security Income: 0
Residents Diagnosed with Mental Illness: 0
Residents Diagnosed with Intellectual Disability: 0
Inspection Report — Jun 28, 2022
Follow-Up
Date: Jun 28, 2022
Visit Reason
The inspection was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to facility compliance, including renewal, complaint, and incident reasons.
Findings
The submitted plan of correction was found to be fully implemented, specifically addressing the issue of outdated signage for key-locking devices in the Secure Dementia Care Unit. The signage was updated and verified acceptable on the day of inspection.
Citations (1)
The directions posted by the keypads in the Secure Dementia Care Unit for operating the home's locking mechanism were not current when observed on 6/28/22, as the code had been changed on 6/24/22.
Report Facts
Residents Served: 128
Secured Dementia Care Unit Residents Served: 31
Hospice Current Residents: 11
Residents 60 Years or Older: 127
Residents with Mobility Need: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Associate Executive Director | Named in training related to plan of correction implementation | |
| Maintenance Director | Named in training and responsible for changing entry codes and signage | |
| Connections Manager | Named in training related to plan of correction implementation |
Inspection Report — Oct 14, 2021
Routine
Date: Oct 14, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Notice — Dec 18, 2020
Date: Dec 18, 2020
Visit Reason
This document serves as a renewal notification and license issuance for Country Meadows of Hershey Personal Care Home. It also 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 the issuance of a regular license following the renewal application and outlines the Department's requirement to conduct an annual inspection.
Report Facts
Inspection Report — Aug 17, 2020
Follow-Up
Date: Aug 17, 2020
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 submitted plan of correction related to resident falls and support plan revisions. Continued compliance must be maintained.
Citations (2)
23a - Activities of Daily Living Assistance: The resident did not receive the required level of staff assistance and supervision as documented in the assessment and support plan, evidenced by multiple falls overnight.
227c - Support Plan Revision: The support plan was not updated within 30 days to address increased services needed after the resident experienced multiple evening and nighttime falls.
Report Facts
Residents Served: 101
Residents Served in Dementia Unit: 28
Hospice Current Residents: 15
Residents 60 Years or Older: 101
Residents with Mobility Need: 43
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Mentioned as conducting audits and random reviews related to falls and support plan revisions | |
| Executive Director | Mentioned as conducting audits and random reviews related to falls and support plan revisions |
Inspection Report — Jun 29, 2020
Renewal
Date: Jun 29, 2020
Visit Reason
The inspection was conducted as part of licensing inspections by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 06/29/2020, 07/02/2020, and 07/06/2020.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Oct 23, 2019
Renewal
Date: Oct 23, 2019
Visit Reason
The inspection was conducted as a renewal review of the Country Meadows of Hershey facility on October 23 and 24, 2019.
Findings
The submitted plan of correction was accepted and fully implemented. The inspection included review of resident support plans and documentation of medical and behavioral care services.
Citations (1)
Regulation 227d requires documentation in the resident's support plan of medical, dental, vision, hearing, mental health, or other behavioral care services. The support plans for Residents 1, 2, and 3 did not document how identified needs would be met.
Report Facts
Residents Served: 126
Residents Served: 33
Current Residents: 16
Notice — Oct 11, 2019
Date: Oct 11, 2019
Visit Reason
This document serves as a renewal notification and license issuance for Country Meadows of Hershey Personal Care Home pursuant to Title 55, PA Code, Chapter 2600.
Findings
The Department confirms receipt of the renewal application and issues a regular license. It advises that an onsite annual inspection will be conducted within the next twelve months to ensure compliance.
Report Facts
Inspection Report — Dec 17, 2018
Renewal
Date: Dec 17, 2018
Visit Reason
The inspection was a renewal visit conducted by the Department's Bureau of Human Services Licensing on December 17 and 18, 2018, to assess compliance with 55 Pa.Code Chapter 2600 for Personal Care Homes.
Findings
The inspection identified multiple violations including inadequate heat source protections, failure to conduct monthly fire drills, incomplete sleeping hours fire drills, improper medication storage, and incomplete pre-admission screening documentation. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (5)
55 Pa.Code §2600.84 - Heat sources such as hot pipes and heaters must have protective guards. The fireplace in the 2nd floor auditorium had a protective heat guard that did not fully extend to prevent resident contact with hot surfaces.
55 Pa.Code §2600.132(a) - An unannounced fire drill must be held at least once a month. A fire drill was not conducted for February and March of 2018.
55 Pa.Code §2600.132(e) - A fire drill during sleeping hours must be held once every 6 months. Several sleeping hours fire drills were conducted late or not completed until months after the scheduled date.
55 Pa.Code §2600.183(d) - Only current prescription, OTC, sample, and CAM medications may be kept in the home. A vial of Humalog, 100 mL, was found in the medication room refrigerator for a resident who left the home on 10/29/18.
55 Pa.Code §2600.224(a) - A determination must be made within 30 days prior to admission on whether the home can meet the resident's needs. Pre-admission screening forms for Residents #2 and #3 were blank on this determination.
Report Facts
Number of Residents Served: 113
Number of Current Hospice Residents: 19
Number of Hospice Residents in past year: 50
Number of Residents Served in Secured Dementia Care Unit: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diana Ponterio | Sr. VP of Operations/Regulatory Compliance | Signed plan of correction documents and named in report header. |
| Amy Wagaman | Administrator | Named as facility administrator on page 2. |
| Douglas Hoover | Department inspector conducting the inspection. | |
| Kellie Cargile | Department inspector conducting the inspection. |
Notice — Oct 17, 2018
Date: Oct 17, 2018
Visit Reason
This document serves as a renewal notification and license issuance for the Personal Care Home 'Country Meadows of Hershey' following the renewal application submitted on October 5, 2018.
Findings
The Department confirms receipt of the renewal application and issues a regular license. It advises that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with Title 55, PA Code, Chapter 2600.
Report Facts
Inspection Report — Jan 3, 2018
Annual Inspection
Date: Jan 3, 2018
Visit Reason
The visit was the Department of Human Services' annual licensing inspection of the facility conducted on January 3 and 4, 2018.
Findings
The facility was found to be in compliance with 55 Pa.Code Ch. 2600 relating to Personal Care Homes.
Notice — Oct 12, 2017
Date: Oct 12, 2017
Visit Reason
This document serves as a renewal approval for the Personal Care Home license for Country Meadows of Hershey and notifies that an annual onsite inspection will be conducted within the next twelve months as required by state regulations.
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 — Jul 26, 2017
Renewal
Date: Jul 26, 2017
Visit Reason
The inspection was a licensing inspection conducted on July 26, 2017, related to renewal and incident investigation at Country Meadows of Hershey.
Findings
The inspection found violations related to posting of the current license and inspection summary, and failure to report alleged abuse incidents to the local area agency on aging. Plans of correction were submitted and partially implemented.
Citations (2)
Regulation 55 Pa.Code §2600.3(c) - The home failed to post the current license and licensing inspection summary in a conspicuous place as required. The renewal inspection was posted immediately following the inspection and the locking mechanism on the display case was removed.
Regulation 55 Pa.Code §2600.15(a) - The home failed to immediately report suspected abuse of residents to the local area agency on aging. The home self-reported incidents to the DHS and implemented steps to ensure future reporting compliance.
Report Facts
Number of Residents Served: 151
Number of Residents Served in Secured Dementia Care Unit: 32
Number of Current Hospice Residents: 9
Number of Hospice Residents in past year: 37
Number of Residents Age 60 or Older: 151
Number of Residents with Mobility Need: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Hamilton | Chief of Senior Living Operations | Named as legal entity representative and signer of plan of correction |
| Amy Wagaman | Administrator | Named as facility administrator |
Inspection Report — Apr 26, 2017
Date: Apr 26, 2017
Visit Reason
The inspection was conducted as a licensing inspection triggered by complaint and incident reports at Country Meadows of Hershey.
Complaint Details
The inspection was triggered by complaints and incidents involving resident injuries and confidentiality breaches. Specific incidents included bruising of resident 1 and a fall and head injury of resident 2.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including failure to implement written policies for incident management, confidentiality breaches in medication administration, incomplete resident assessments, and insufficient staff training in dementia care.
Citations (5)
55 Pa.Code §2600 2600.16(b) - The home failed to create and implement written policies for prevention, reporting, notification, investigation, and management of reportable incidents as evidenced by lack of documentation for bruising and fall injuries.
55 Pa.Code §2600 2600.17 - Resident records were not kept confidential as medication administration records were left open and accessible in a hallway.
55 Pa.Code §2600 2600.225(c) - Resident 2's annual assessment did not identify changes in mobility and needs associated with frequent falls, and no subsequent assessment was completed.
55 Pa.Code §2600 2600.234(d) - The support plan was not revised to reflect a change from one-person to two-person assist for Resident 2, and documentation was incomplete.
55 Pa.Code §2600 2600.236 - Direct care staff person B had only 2 hours of dementia care training during the April 2016-March 2017 training year, less than the required 6 hours.
Report Facts
Number of Residents Served: 122
Number of Residents Served in Secured Dementia Care Unit: 32
Number of Current Hospice Residents: 9
Number of Hospice Residents in Past Year: 28
Number of Residents Age 60 or Older: 122
Number of Residents with Mobility Need: 32
Number of Residents with Physical Disability: 1
Inspection Report — Jan 11, 2017
Renewal
Date: Jan 11, 2017
Visit Reason
The inspection was conducted as part of the annual licensing renewal process for Country Meadows of Hershey.
Findings
The facility was found to be in compliance with 55 Pa.Code Chapter 2600 after corrections were made. One violation was identified involving an unprotected electric fireplace in the secured dementia care unit, which was immediately corrected by disconnecting the fireplace.
Citations (1)
55 Pa.Code 2600.84 requires heat sources accessible to residents to have protective guards or insulation. An electric fireplace in the secured dementia care unit lacked a protective guard to prevent resident contact.
Report Facts
Number of Residents Served: 122
Number of Current Hospice Residents: 16
Number of Hospice Residents in Past Year: 25
Notice — May 26, 2016
Date: May 26, 2016
Visit Reason
The document is a response to a request for a waiver of Pennsylvania Code qualifications for direct care staff persons at a personal care home.
Findings
The Department of Human Services granted the requested waiver, determining that the non-U.S. educational program is similar to U.S. educational requirements.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tara Pride | Director of Regulatory Implementation | Signed the waiver approval letter. |
Notice — March 9, 2017
Date: March 9, 2017
Visit Reason
The document is a response to a request for a waiver of Pennsylvania Code Chapter 2600 relating to qualifications for direct care staff persons at Country Meadows of Hershey.
Findings
The Department of Human Services granted the requested waiver under the authority of 55 Pa.Code § 2600.19, determining that the non-U.S. educational program is similar to U.S. educational requirements.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jaqueline L. Rowe | Director | Signed the waiver approval letter. |
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