Legend Personal Care and Memory Care of Lititz.

“Resident #1's prescription medication (Moxifloxacin 0.5% eye drops) had conflicting labeling: the pharmacy label stated 1 drop in left eye 3 times daily, but the Medication Administration Record stated twice daily.”

“An 8 fluid ounce container of Ensure Chocolate therapeutic nutrition drink belonging to resident #2 was stored in the medication cart without being labeled with the resident's name.”

“Multiple instances of failure to follow prescriber's orders: Resident #1's blood sugar was not checked before breakfast on 6/9/25 (prescribed 3 times daily); Resident #2 did not receive prescribed Ensure Chocolate twice daily on 5/26/25 and was late on 6/10/25; Resident #3 did not receive prescribed Repaglinide on 6/10/25 at 12:00pm; Resident #3 did not have prescribed TED knee stockings applied on 5/25/25.”

“Resident's confidential narcotic count information (Clonazepam 0.5mg) was unlocked, unattended, and accessible on top of medication cart in the Secure Dementia Care Unit. This was a repeated violation from 9/19/24.”

“Two staff members hired in 2023 did not receive required training during the 2024 training year on: (1) Instruction on meeting the needs of residents as described in the preadmission screening form, assessment tool, medical evaluation and support plan, and (2) Personal care service needs of the resident.”

“Resident #2's Lantus Solostar prescription was mislabeled. The pharmacy label stated to inject 15 units at bedtime, but the actual order was to inject 18 units subcutaneously every day. This was a repeated violation from 9/19/24.”

“Two documentation errors were identified: Resident #2 had a blood glucose reading of 133 at 4:37 PM but it was documented as 134; Resident #3 had a blood glucose reading of 134 at 4:40 PM but this reading was not documented at all. This was a repeated violation from 9/19/24 and 7/2/24.”

“Resident #4's medication administration record showed an inconsistency: the order for Donepezil HCL 10 mg stated to take one tablet by mouth daily at bedtime, but the administration time was documented as 8:00 AM instead of bedtime.”

“A resident refused several prescribed medications on multiple dates (1/18/25, 1/23/25, and 2/8/25), but the home failed to document the refusals in the resident's record or report them to the prescriber within 24 hours.”

“Multiple physical altercations between residents resulted in injuries including fractured nose, abrasions, and facial trauma. Facility failed to prevent resident-to-resident abuse despite witnessing incidents. Facility staff witnessed four separate incidents involving physical altercations between residents, resulting in injuries such as fractured nose, abrasions to back and chin, lip injury, and redness to struck areas.”

“The home did not provide each resident with individual towels, washcloths, and soap. Residents were required to supply these items per the home's contract, in violation of regulation requirements.”

“Staff Member B hired on an unspecified date does not have a required Pennsylvania criminal history background check on file.”

“Staff Member C, who began working in the home, has not received required first-day orientation on evacuation procedures and staff duties and responsibilities during fire drills and emergency evacuation.”

“The home failed to report suspected abuse/neglect of a resident to the Area Agency on Aging. A resident requiring total physical assistance with toileting was left alone in the bathroom covered in bowel movement when staff failed to provide necessary assistance during shift change.”

“The home failed to report an incident of neglect to the Department within 24 hours as required. A resident was left alone in the bathroom covered in bowel movement and did not receive required total physical assistance with toileting.”

“A resident requiring total physical assistance with toileting was neglected when left alone in the bathroom during shift change, resulting in the resident being covered in bowel movement. The resident did not receive required care.”

“The home failed to report suspected abuse/neglect of a resident to the Area Agency on Aging. A resident requiring total physical assistance with toileting was left alone in the bathroom covered in bowel movement when staff failed to provide necessary assistance during shift change.”

“The home failed to report an incident of neglect to the Department within 24 hours as required. A resident was left alone in the bathroom covered in bowel movement and did not receive required total physical assistance with toileting.”

“A resident requiring total physical assistance with toileting was neglected when left alone in the bathroom during shift change, resulting in the resident being covered in bowel movement. The resident did not receive required care.”

“Staff Member B hired on an unspecified date does not have a required Pennsylvania criminal history background check on file.”

“Staff Member C, who began working in the home, has not received required first-day orientation on evacuation procedures and staff duties and responsibilities during fire drills and emergency evacuation.”

“Resident was prescribed medication to apply on chest twice daily for 7-14 days, but it was not administered from 3/13/24 through 3/21/24. Additionally, daily medications prescribed for 8 am administration were not given until after 12 pm on 3/19/24 due to medication unavailability at the home.”

“The home failed to report multiple incidents to the Department within required timeframes. An unwitnessed fall with head injury and nosebleed on an unspecified date was not reported. A monetary loss of approximately $12,000 reported in an unspecified month was not reported until 11/20/23. A monetary loss of approximately $42,000 on an unspecified date was not reported to the Department.”

“Between November 2022 and April 2023, two staff members misappropriated a total of $12,000 from a resident's personal bank account, constituting neglect and financial abuse.”

“The home failed to maintain the required ratio of 1 staff person trained in first aid and CPR for every 50 residents. On 11/28/23 and 12/2/23 from 10:00 pm to 6:00 am with approximately 63 residents, only 1 trained staff was present. On 12/5/23 from 10:00 pm to 6:00 am with approximately 63 residents, no trained staff were present.”

“Poisonous materials including Colgate toothpaste and Secret deodorant with poison warning labels were left unlocked, unattended, and accessible to a resident. The resident had not been assessed as capable of safely recognizing and using poisons.”

“Class II violation with calculated fine of $350 per day (70 residents × $5 per resident per day). Mandated correction date is 5 calendar days from mailing date of March 18, 2024 letter.”

“The home failed to report multiple incidents to the Department within required timeframes. An unwitnessed fall with head injury and nosebleed on an unspecified date was not reported. A monetary loss of approximately $12,000 reported in an unspecified month was not reported until 11/20/23. A monetary loss of approximately $42,000 on an unspecified date was not reported to the Department.”

“Between November 2022 and April 2023, two staff members misappropriated a total of $12,000 from a resident's personal bank account, constituting neglect and financial abuse.”

“The home failed to maintain the required ratio of 1 staff person trained in first aid and CPR for every 50 residents. On 11/28/23 and 12/2/23 from 10:00 pm to 6:00 am with approximately 63 residents, only 1 trained staff was present. On 12/5/23 from 10:00 pm to 6:00 am with approximately 63 residents, no trained staff were present.”

“Poisonous materials including Colgate toothpaste and Secret deodorant with poison warning labels were left unlocked, unattended, and accessible to a resident. The resident had not been assessed as capable of safely recognizing and using poisons.”

“Class II violation with calculated fine of $350 per day (70 residents × $5 per resident per day). Mandated correction date is 5 calendar days from mailing date of March 18, 2024 letter.”

“A resident's medication went missing after staff member left it unattended on top of a medication cart. The medication was never located and police were notified.”

“Resident 4 reported requesting a PRN medication for 3 days without receiving it, and the medication administration record showed no documentation of administration with no hold orders in place during that timeframe.”

“A small white round pill was found in medication cart 1, indicating improper medication storage.”

“A large piece of furniture (buffet) was blocking egress from the exit hallway in the Secure Dementia Care Unit near resident bedroom 311, creating an unobstructed egress violation.”

“Two residents did not have initial medical evaluations completed within the required 60 days prior to admission or 30 days after admission timeframe.”