Inspection Report
Complaint Investigation
Census: 35
Capacity: 36
Deficiencies: 5
May 13, 2025
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 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.
Complaint Details
The inspection was triggered by a complaint and was unannounced. The plan of correction was fully implemented as of 05/13/2025.
Deficiencies (5)
| Description |
|---|
| 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
License Capacity: 36
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
Complaint Investigation
Census: 33
Capacity: 36
Deficiencies: 3
Nov 21, 2024
Visit Reason
The inspection was conducted as a complaint investigation following a report of incidents at the facility.
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.
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.
Deficiencies (3)
| Description |
|---|
| 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
License capacity: 36
Total daily staff: 37
Waking staff: 28
Current hospice residents: 3
Residents 60 years or older: 33
Residents with mobility need: 4
Inspection Report
Complaint Investigation
Census: 29
Capacity: 36
Deficiencies: 0
Feb 8, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 02/08/2024.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and no follow-up was required.
Report Facts
License Capacity: 36
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
Renewal
Census: 31
Capacity: 36
Deficiencies: 5
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.
Deficiencies (5)
| Description |
|---|
| 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
License Capacity: 36
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
Complaint Investigation
Census: 28
Capacity: 36
Deficiencies: 0
Dec 2, 2022
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or regulatory citations were found, indicating no substantiated issues.
Report Facts
Residents Served: 28
License Capacity: 36
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
Complaint Investigation
Census: 28
Capacity: 36
Deficiencies: 0
Dec 2, 2022
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related; no deficiencies were found and follow-up was not required.
Report Facts
License Capacity: 36
Residents Served: 28
Current Residents in Hospice: 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
Renewal
Census: 30
Capacity: 36
Deficiencies: 7
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.
Deficiencies (7)
| Description |
|---|
| 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
License Capacity: 36
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
Capacity: 36
Deficiencies: 0
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
Total licensed capacity: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal license notification letter |
Notice
Capacity: 36
Deficiencies: 0
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
Total licensed capacity: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
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