Legend Personal Care and Memory Care of Allentown.

“Resident's most recent assessment did not accurately reflect cognitive status. The assessment indicated no short-term memory problems, but the resident's medical evaluation documented short-term memory deficits. The assessment and medical evaluation were not aligned.”

“The home failed to report medication errors to the Department within 24 hours as required. Medication errors for a resident on multiple dates were not reported to the Department's personal care home regional office or complaint hotline.”

“A resident's initial medical evaluation was completed but does not indicate whether the resident's needs can be met in a personal care home, as required by regulation.”

“A verbal medication order was taken by an unlicensed staff person to administer medication to a resident, which violates the requirement that medication changes be made in writing by a prescriber or through proper emergency procedures with licensed personnel.”

“The home failed to follow a physician's order for sliding scale insulin administration. On multiple dates, residents with blood sugar readings requiring insulin doses were administered 0 units or incorrect amounts of insulin contrary to the prescriber's orders.”

“Medication errors were not immediately reported to the resident, the resident's designated person, or the prescriber as required by regulation. Multiple medication errors were identified but reporting was not completed in a timely manner.”

“A resident was admitted to the home but the preadmission screening form was not completed, failing to document that the resident's needs could be met by the home's services.”

“A resident requiring assistance with transferring in and out of bed/chair did not receive this assistance as required and was found lying by bed with an injury to nose.”

“The Long-Term Care Ombudsman requested access to a resident's Electronic Medication Record on multiple occasions, but facility staff (MedTech and Staff A) denied immediate access to the records, violating the requirement to provide immediate access to the home, residents, and records to Ombudsman representatives.”

“On dates 6/13/25 and 6/14/25, the facility had 54 residents with 17 in the Secured Dementia Care Unit requiring constant supervision, 4 residents requiring two-person assist for transfers, and 21 requiring one-person assist, but only 3 staff worked the 11:00 p.m. to 7:00 a.m. shift, which is insufficient to safely evacuate all residents in an emergency.”

“Fire drill records contained inaccurate information: a drill on 1/18/25 at 2:45 a.m. documented 12 staff participating when only 4 actually participated, and a drill on 5/10/25 documented only 6 residents evacuated when 49 actually evacuated, failing to accurately record the number of staff and residents evacuated.”

“During a fire drill on an unspecified date at 4:02 p.m., two residents did not evacuate to a designated meeting place away from the building or within the fire-safe area. Staff indicated they placed a pillow in the door of non-evacuating residents' rooms rather than ensuring compliance with evacuation procedures.”

“A resident's annual assessment completed on an unspecified date indicated the resident received Hospice services, but the resident's support plan did not indicate what services hospice was providing, failing to accurately reflect the resident's needs within the required 30-day revision period.”

“Medication errors were not reported to the Department within 24 hours as required. One resident's medication error was reported late, and another resident's medication error reporting timeline was not met.”

“Staff failed to initial the Medication Administration Record to indicate that medications were administered at the prescribed times for five residents on specified dates.”

“Medication refusals by residents were not documented on the Medication Administration Record and were not reported to the prescriber within 24 hours as required.”

“The home did not follow the prescriber's orders for medication administration. One resident's new medication was administered at the wrong time (8:00 p.m. instead of bedtime), and another resident's medication doses were administered late and outside prescribed time parameters.”

“Medication errors were not immediately reported to the resident, the resident's designated person, and the prescriber as required. Two medication errors occurred but were not communicated to families or physicians at the time.”

“An incident report for a resident's unwitnessed fall was not submitted to DHS within 24 hours. The fall occurred at 7:20 a.m. but the incident report was not sent to DHS until 5:30 p.m., exceeding the required 24-hour reporting timeframe.”

“A resident experienced 8 falls over a 2-month period with 5 falls occurring within a specific timeframe, including one resulting in a forehead laceration requiring stitches and another resulting in multiple rib fractures. The facility failed to implement adequate safety measures beyond PT/OT services to prevent falls and ensure resident safety.”

“A resident was put into bed against their wishes by staff members. The resident is unable to get out of bed independently and requires two-person assist, constituting involuntary confinement.”

“A resident's assessment plan was not updated to reflect significant changes in condition, including increased need for assistance with dressing and standby assistance with ambulation that occurred in recent months.”

“A resident in the secure dementia unit had a Medical Evaluation form that did not include a diagnosis of dementia or Alzheimer's disease in section 2, did not indicate need for secure dementia care in section 4, and was missing vital signs including height, weight, pulse rate, temperature, and blood pressure.”

“Two incidents involving Staff A were not reported to the Department within the mandatory 24-hour timeframe. On 10/27/2024 at 12:30am, Staff A grabbed and pinched a resident's hands after making threatening statements. On 10/27/2024 at 1:15am, Staff A grabbed a resident's arm near the elbow while the resident was resisting care. Both incidents were witnessed by Staff B but not reported until 10/29/2024. This is a repeat violation.”

“Staff A grabbed and applied pressure to a resident's fingers while the resident was resisting care, and later grabbed the resident's arm while the resident was resisting care and crying out in pain. Both incidents were witnessed by Staff B and admitted to by Staff A. The facility failed to protect the resident from physical abuse and neglect. This is a repeat violation from 9/5/2023.”

“Staff A threatened to hurt a resident by saying 'You're not going to pinch my fingers. I'll pinch your fingers before you pinch mine' and grabbed the resident's hands. Staff A also used vulgar language and spoke disrespectfully about the resident and other staff members in front of residents. These actions violated the requirement that residents be treated with dignity and respect. This is a repeat violation from 8/15/2024.”

“A resident's current Resident Assessment and Support Plan dated 8/10/24 was not updated to reflect that the resident had been receiving Ascend Health Hospice Services since a documented date. The support plan failed to document the medical/hospice care services being provided to the resident.”

“On 10-1-24, menus were posted only through 10-5-24 and were not posted one week in advance as required. This was a repeated violation from prior inspections on 12-13-23 and 3-5-24.”

“Resident #2's Latanoprost .005 eye drops in the medication cart lacked a date of first use or expiration date. The manufacturer recommends discarding the medication after 6 weeks. This was a repeated violation from 12-13-23.”

“Resident #5's medication (Furosemide 40mg) was popped out of the bubble pack and taped back without first checking the resident's blood pressure parameters as required. The blood pressure was too low to safely administer the medication. This was a repeated violation from prior inspections on 2-1-24 and 4-18-24.”

“A small fire started in the kitchen stove on 9-16-24, and the home did not pull the fire alarm when the fire was observed as required by the home's fire safety policies. Although the fire was extinguished within 60 seconds and the Residence Director was present, the pull station was not manually activated.”

“The door leading from personal care to the memory care unit was not functioning for approximately two weeks. The keypad used to enter/exit the memory care from personal care would not always open when the code was entered, preventing staff and family members from exiting the unit through this door.”

“The facility failed to consistently follow the resident's support plan regarding assistance with bladder management and changing soiled undergarments. The resident called for assistance but no staff responded to help them.”

“A resident reported that staff member was rough with care, including scolding the resident for incontinence accidents, pulling up the resident's pants forcefully, and changing undergarments in the living room instead of the bathroom. The resident was fearful of the staff member.”

“A soiled diaper was laying on the floor next to a resident's recliner and a wet substance resembling urine was present in the carpet. The resident reported calling for assistance earlier in the day but no staff responded.”

“Staff failed to respond to resident call bells in a timely manner. One resident's call bell initiated at 6:59pm was not responded to for 13 hours, 25 minutes, and 49 seconds. Multiple instances documented where call bells went unanswered for over 15 minutes or were acknowledged but not responded to for over an hour. Additionally, third shift staff did not use task sheets to document incontinence care for a resident requiring toileting and brief changes.”

“On several days between specified dates, there were no staff present in the home who were trained in medication administration, despite the home serving residents with PRN medications.”

“Medication administration failed to follow prescriber's orders. Resident #2 had medications administered when heart rate parameters indicated medications should have been held on multiple occasions. Resident #3 had a tablet administered when systolic blood pressure exceeded the hold parameter. This was a repeat violation from prior inspections.”

“A resident was administered a tablet every morning at 8am despite having a heart rate less than 60 on multiple occasions (specific dates not fully legible in document), contrary to prescriber's instructions to hold the medication for heart rate less than the specified threshold. No documentation indicated the medication was held in accordance with physician's orders.”

“Violation cited under 55 Pa Code § 2600.187d with a calculated fine of $355 (71 residents × $5 per day).”

“The Department revoked the facility's Certificate of Compliance (License #231390) dated December 1, 2023 to December 1, 2024 and issued a First Provisional license based on violations found during licensing inspections on December 13, 2023, February 1, 2024, March 5, 2024, and April 18, 2024.”

“Resident #5 did not receive prescribed Novolog Flexpen at 8pm on 4/9/24 because the resident was out with family. A reportable incident was not completed by the home regarding this missed medication administration.”

“Violation cited under 55 Pa Code § 2600.185a with a calculated fine of $355 (71 residents × $5 per day).”

“Violation cited under 55 Pa Code § 2600.185a with a calculated fine of $355 (71 residents × $5 per day).”

“Violation cited under 55 Pa Code § 2600.187d with a calculated fine of $355 (71 residents × $5 per day).”

“Resident #5 did not receive prescribed Novolog Flexpen at 8pm on 4/9/24 because the resident was out with family. A reportable incident was not completed by the home regarding this missed medication administration.”

“The Department revoked the facility's Certificate of Compliance (License #231390) dated December 1, 2023 to December 1, 2024 and issued a First Provisional license based on violations found during licensing inspections on December 13, 2023, February 1, 2024, March 5, 2024, and April 18, 2024.”

“Resident #5 did not receive prescribed Novolog Flexpen at 8pm on 4/9/24 because the resident was out with family. A reportable incident was not completed by the home regarding this missed medication administration.”

“Violation cited under 55 Pa Code § 2600.185a with a calculated fine of $355 (71 residents × $5 per day).”

“Violation cited under 55 Pa Code § 2600.187d with a calculated fine of $355 (71 residents × $5 per day).”

“The Department revoked the facility's Certificate of Compliance (License #231390) dated December 1, 2023 to December 1, 2024 and issued a First Provisional license based on violations found during licensing inspections on December 13, 2023, February 1, 2024, March 5, 2024, and April 18, 2024.”

“Resident #5 did not receive prescribed Novolog Flexpen at 8pm on 4/9/24 because the resident was out with family. A reportable incident was not completed by the home regarding this missed medication administration.”

“Violation cited under 55 Pa Code § 2600.185a with a calculated fine of $355 (71 residents × $5 per day).”

“Violation cited under 55 Pa Code § 2600.187d with a calculated fine of $355 (71 residents × $5 per day).”

“The Department revoked the facility's Certificate of Compliance (License #231390) dated December 1, 2023 to December 1, 2024 and issued a First Provisional license based on violations found during licensing inspections on December 13, 2023, February 1, 2024, March 5, 2024, and April 18, 2024.”

“Resident #1's assessment and support plan were not updated to reflect current support needs, including more frequent safety checks or occupational/physical therapy, and did not document ordered compression stockings or new incontinence of bladder.”

“Resident #1 suffered unexplained bruises to hands and forearms and had multiple unwitnessed falls requiring medical evaluation within one month, constituting neglect due to lack of supervision. Additionally, staff failed to adequately safeguard Resident #1 when another resident pushed them from behind, resulting in a laceration to the mouth and hand.”

“Resident #1's support plan was not revised within 30 days to address new incontinence of bladder following recent falls and to document ordered compression stockings for daily use following hospitalization.”