Legend Personal Care and Memory Care of Lancaster

A resident engaged in inappropriate sexual activity and fondling of other residents in common areas of the Secured Dementia Care Unit.

A pungent scent of urine and body odor was detected in a resident room.

Multiple incidents of residents in the Secured Dementia Care Unit engaging in sexualized behaviors and being found naked in apartments without appropriate assessments for ability to consent or one-to-one supervision.

Two medication carts and their associated laptops were left unlocked, unattended, and accessible, exposing resident confidential information.

A resident eloped from the facility due to an improperly latching door, and a sexual act occurred between two residents in the SDCU without assessments for ability to consent.

The home failed to report two incidents (a potential physical abuse incident and a resident elopement) to the Department within the required 24-hour timeframe.

The personal care home failed to post the current license, the inspection summary, and the regulations in a conspicuous and public place.

The preadmission screening form did not include a determination that the resident's needs could be met by the services provided by the home.

The resident's assessment and support plan did not include updated information regarding needs following a change in condition.

The home failed to follow prescriber's orders by not administering medications at the prescribed times for residents.

A resident was found on the floor with a bloody nose and a diagnosed nasal fracture following an incident.

Three staff members were identified as not having received required fire safety and emergency preparedness orientation.

Resident medical evaluations were missing required information such as height, weight, blood pressure, pulse, temperature, and body positioning.

The home failed to report an incident to the Department within 24 hours regarding a resident's medication not being available.

The resident's initial support plan for the Secure Dementia Care Unit was not completed within 72 hours of admission.

Discrepancies were observed between the medication administration record (MAR) and actual blood sugar readings for multiple residents.

A resident's initial medical evaluation was not completed within the required timeframe following admission.

The home failed to follow prescriber orders as several medications were not administered because they were unavailable in the home.

A resident's written initial assessment was not completed within 15 days of their admission.