Legend Personal Care and Memory Care of Lancaster.

“Resident engaged in multiple incidents of inappropriate sexual activity with other residents in the facility's Secured Dementia Care Unit, including sexual acts in resident rooms and fondling in common areas. The resident, who lacks capacity to recall person, place, and time, was not adequately supervised to prevent these incidents despite implemented monitoring protocols.”

“A pungent scent of urine and body odor was detected in a resident's room at approximately 11:30 AM, indicating unsanitary conditions were being maintained.”

“Two medication carts were left unlocked, unattended, and accessible with unlocked laptops containing resident medical information including prescribed medications. The medication administration staff failed to log out and secure the laptops when leaving the carts unattended.”

“Multiple incidents of inappropriate sexual contact between residents in the Secured Dementia Care Unit were not properly managed. Residents were observed in sexual situations without assessments of their ability to consent. The home did not place one resident with one-to-one supervision during waking hours until several days after the initial incident. This is a repeated violation.”

“Five staff persons did not receive required annual training in medication self-administration and instruction on meeting resident needs as described in preadmission screening forms, assessment tools, medical evaluations and support plans during the 2024 training year.”

“The home failed to report a suspected abuse incident (staff member C allegedly hitting a resident) within 24 hours to the Department. The incident occurred on 4/2/25 but was not reported to the Department until 4/3/25 at 1:07 PM. Additionally, a resident elopement incident on 4/6/25 was not reported to the Department until 4/7/25 at 3:15 PM.”

“A resident in the Secured Dementia Care Unit eloped from the facility and was found 5.5 miles away by police. Staff failed to include the resident in required rounds (8:00-8:30 PM and 9:00-9:30 PM). The exit door the resident used to leave did not completely latch. Additionally, two residents with dementia diagnoses and no documented ability to consent were found engaged in sexual contact; neither resident had been evaluated by a medical professional to determine consent capacity.”

“Poisonous materials were found unlocked, unattended, and accessible to residents. On 4/16/25 at approximately 10:15 AM, a Dove Advanced Care Deodorant stick and Eucerin Itch Relief Intensive Calming Lotion (both with poison warnings) were accessible in a shared resident room. At 10:20 AM, two containers of Clorox disinfecting wipes were unlocked and accessible in another resident room. Residents had not been assessed as capable of safely recognizing and using these poisonous materials.”

“Sanitary conditions were not maintained in a resident bathroom. On 4/16/25 at approximately 10:57 AM, a portable urinal hanging on the toilet grip bar had urine caked around the rim, the toilet had feces splatter inside and on the seat, and the bathroom trash can had feces on the edge of the lid.”

“On 2/7/25 at 12:00 PM, a representative of Protective Services with Lancaster area agency on aging did not receive immediate access to the home, residents, and records as required.”

“The home's most recent renewal license inspection summary (LIS) dated 4/9/25, partial inspection LIS dated 5/30/24, and partial inspection LIS dated 10/3/24 were not posted in a conspicuous and public place in the home.”

“The administrator did not provide immediate access to requested records including census information with demographic data (delayed from 9:45 AM to 11:45 AM), administrator's training records (delayed until 2/26/25 at 9:45 AM), fire drill records from 2024 to current (delayed until 2/26/25 at 9:30 AM), medication training records (delayed until 2/26/25 at 1:45 PM), and 2024 reportable incidents (could not be located and staff attempted to retrieve from emails).”

“Violation cited for which a civil money penalty is being assessed at the rate of $5 per resident per day (77 residents × $5 = $385 per day), with a mandated correction date of 5 calendar days from the mailing date of the letter.”

“The facility failed to follow prescriber's orders for two residents by not administering medications at the prescribed frequency and times. One resident was prescribed medication to take 2 puffs every 6 hours for 3 days then as needed, but received only 6 doses over the initial period. Another resident was prescribed 1 capsule every 8 hours for 3 days then as needed, but received only 5 doses over the initial period.”

“The facility failed to mark the determination box on a resident's preadmission screening form indicating that the needs of the resident can be met by the services provided by the home. This is a repeated violation.”

“The facility failed to complete additional assessments when significant changes occurred for two residents. One resident was prescribed medication upon hospital discharge but the assessment did not document this need. Another resident experienced cognitive decline and was determined to need placement in a Secure Dementia Care Unit, but the assessment did not document the cognitive decline or how needs would be met until transfer.”

“The facility failed to obtain documentation that a resident and the resident's designated person had not objected to the resident's admission to the Secure Dementia Care Unit. The resident's power of attorney refused to come sign a new lease at the time.”

“A resident was found sitting on the floor in the hallway with a bloody nose and complained of being struck in the nose by another resident. The resident was taken to the hospital and diagnosed with a nasal fracture.”

“Three staff members (Staff A, Staff B, and Staff C) did not receive orientation training in fire safety and emergency preparedness topics required on or during their first work day, including evacuation procedures, staff duties, designated meeting places, smoking safety, fire extinguishers, smoke detectors and fire alarms, and emergency services notification.”

“Four residents' medical evaluations were incomplete or missing required information: one evaluation lacked height, weight, blood pressure, pulse, and temperature; two evaluations lacked body positioning/movement information and one lacked the medical professional's name; and one evaluation lacked height and weight.”

“A resident prescribed topical medication to be applied daily and as needed to open areas was not available to be given on 10/3/24, indicating a failure to maintain safe storage, access, and security procedures for medications.”

“Two residents' support plans did not document required care information: one plan did not include information about Foley leg bag maintenance and supply procurement; another plan inaccurately stated the resident was independent with toileting and transfers when the resident required assistance, and did not document daily leg cleaning and wrapping services. This is a repeated violation from 4/9/24.”

“A resident admitted to the Secured Dementia Care Unit did not have an initial support plan developed and implemented within 72 hours of admission as required.”

“A resident's initial medical evaluation was not completed within 60 days prior to admission or within 30 days after admission as required.”

“A resident's prescribed daily medication was not administered due to unavailability in the home, and this incident was not reported to the Department within 24 hours as required. This is a repeated violation from previous inspections.”

“Discrepancies were found between blood sugar readings documented in a resident's medication administration record (MAR) and actual readings in the resident's record, indicating failure to properly implement safe storage and access procedures for medications. This is a repeated violation from previous inspections.”

“Multiple residents' prescribed medications were not administered as ordered by the prescriber because the medications were not available in the home. This is a repeated violation from previous inspections.”

“A resident's initial assessment was not completed within 15 days of admission as required by regulation.”

“The facility failed to report multiple incidents to the Department within 24 hours as required: a gas odor detection incident on 9/25/23 where residents were evacuated, an unwitnessed fall by Resident 3 on an unspecified date in 2024 resulting in head injury and ER transport, and an unwitnessed fall by Resident 6 resulting in hip fracture. This was a repeated violation.”

“A resident engaged in various incidents involving verbal and physical aggression, but the resident's assessment and support plan did not reflect these behavioral issues or document a plan to meet the service needs. This is a repeat violation.”

“Multiple medication administration errors: one resident prescribed a medication once per week was administered more than once per week and on incorrect days; another resident's prescribed daily allergy medication was not administered on specified dates; a third resident's prescribed eye drops were not administered for an extended period because the medication was not available. This is a repeat violation.”

“Resident was neglected and physically abused. Staff observed multiple incidents of residents hitting and ramming other residents, including one incident resulting in a skin tear. This is a repeat violation.”

“The van used to transport residents had an expired inspection sticker and was not current on vehicle inspections.”

“A medication cart was found unlocked, unattended, and accessible in the main hallway with keys hanging out of the lock. This is a repeat violation.”

“A resident was administered a medication prescribed for and belonging to a different resident.”

“Glucometer readings and medication administration records (MAR) were not properly cross-referenced for a resident. Multiple glucometer readings were entered multiple times on the MAR, and discrepancies existed between glucometer readings/times and MAR entries, including instances where readings differed or were recorded as 'Resident Refused' without matching glucometer data.”

“Violation related to facility requirements under 2600.185(a); civil money penalty assessed.”

“Violation related to facility requirements under 2600.190(a); civil money penalty assessed.”

“Violation related to facility requirements under 2600.227(g); civil money penalty assessed.”

“The home's current license and licensing inspection summaries were not posted in a conspicuous and public place in the home.”

“Resident 1 was found on the floor and hospitalized with 6 fractured ribs. The home did not report this incident to the Department within 24 hours. This is a repeated violation.”

“Resident 2, admitted on an unspecified date in June 2023, did not have a resident-home contract completed until after admission, not within 24 hours.”

“The resident-home contract for Resident 2 was not signed by the administrator or representative of the home. The resident-home contracts for Resident 3 and Resident 4 were not signed by the resident, administrator or representative of the home.”

“Violation related to facility requirements under 2600.42(b); civil money penalty assessed.”

“Violation related to facility requirements under 2600.52; civil money penalty assessed.”

“Violation related to facility requirements under 2600.63(a); civil money penalty assessed.”

“Violation related to facility requirements under 2600.85(d); civil money penalty assessed.”

“Multiple violations of Personal Care Homes regulations resulted in revocation of the facility's Certificate of Compliance and issuance of a First Provisional License.”

“Violation related to facility requirements under 2600.190(a); civil money penalty assessed.”

“The home's current license and licensing inspection summaries were not posted in a conspicuous and public place in the home.”

“Resident 1 was found on the floor and hospitalized with 6 fractured ribs. The home did not report this incident to the Department within 24 hours. This is a repeated violation.”

“Resident 2, admitted on an unspecified date in June 2023, did not have a resident-home contract completed until after admission, not within 24 hours.”

“The resident-home contract for Resident 2 was not signed by the administrator or representative of the home. The resident-home contracts for Resident 3 and Resident 4 were not signed by the resident, administrator or representative of the home.”

“Violation related to facility requirements under 2600.42(b); civil money penalty assessed.”

“Violation related to facility requirements under 2600.52; civil money penalty assessed.”

“Violation related to facility requirements under 2600.63(a); civil money penalty assessed.”

“Violation related to facility requirements under 2600.85(d); civil money penalty assessed.”

“Violation related to facility requirements under 2600.185(a); civil money penalty assessed.”

“Violation related to facility requirements under 2600.227(g); civil money penalty assessed.”

“Multiple violations of Personal Care Homes regulations resulted in revocation of the facility's Certificate of Compliance and issuance of a First Provisional License.”