33 Reports
Inspection Report — Mar 24, 2026
Follow-Up
Date: Mar 24, 2026
Visit Reason
The visit was conducted as a follow-up to verify the full implementation of a previously submitted plan of correction for identified violations.
Findings
The submitted plan of correction was determined to be fully implemented. The facility was found to be in compliance with the required regulations, and continued compliance must be maintained.
Citations (8)
2600.121a Stairways, hallways, doorways, passageways and egress routes must be unlocked and unobstructed. The exit door in the Secure Dementia Care Unit adjacent to resident room #311 was not functioning, preventing immediate egress.
2600.125b Combustible materials shall be inaccessible to residents. A propane tank was observed unlocked and accessible to residents under the grill within the personal care courtyard.
2600.141a A resident shall have a medical evaluation documented within 60 days prior to admission or within 30 days after admission. Resident #1's medical evaluation was not completed until 5/27/25.
2600.190a Staff must complete a Department-approved medication administration course within the past 2 years. Staff Member A's medication administration training record lacked a completed Initial Summary and Qualification User Report, and the annual practicum was not completed on time.
2600.190c A record of training shall be kept including staff trained, date, source, trainer name, and course completion. Staff Member A's training record did not include a completed Initial Summary and Qualification User Report, and the Annual Practicum was not completed within the expected timeframe.
2600.225a A resident shall have a written initial assessment documented within 15 days of admission. Resident #1's assessment was not completed until 6/10/25.
2600.227a A resident requiring personal care services shall have a written support plan developed and implemented within 30 days of admission. Resident #1's initial support plan was not completed until 6/10/25.
2600.233c If key-locking devices prevent immediate egress, directions for operation shall be conspicuously posted near the device. Directions were not conspicuously posted near the door adjacent to resident room # in the Secure Dementia Care Unit.
Report Facts
Residents Served: 73
Secure Dementia Care Unit Residents Served: 29
Current Hospice Residents: 5
Residents Age 60 or Older: 72
Residents with Mobility Need: 29
Inspection Report — Jan 13, 2026
Complaint Investigation
Date: Jan 13, 2026
Visit Reason
The inspection was conducted as a complaint investigation to review allegations related to resident behaviors and facility compliance.
Complaint Details
The visit was complaint-related, focusing on allegations of inappropriate sexual behavior by a resident in the secured dementia care unit. The facility's plan of correction was accepted and fully implemented.
Findings
The facility was found to have issues related to resident sexual behaviors and supervision in the secured dementia care unit. The facility implemented increased supervision and staff training to address these concerns, with ongoing monitoring planned.
Citations (1)
Regulation 2600.42b: A resident exhibited multiple inappropriate sexual behaviors with other residents, including incidents in female resident rooms and common areas. The facility implemented 1-1 supervision and frequent staff checks to monitor and redirect the resident.
Report Facts
Residents Served: 77
Secured Dementia Care Unit Residents Served: 40
Hospice Current Residents: 4
Residents Age 60 or Older: 76
Residents with Mobility Need: 41
Residents Rights Review Frequency: 5
Inspection Report — Sep 24, 2025
Renewal
Date: Sep 24, 2025
Visit Reason
The inspection was conducted as a renewal licensing inspection of Legend Personal Care and Memory Care of Lancaster, including multiple visits on September 24-25, 2025 and November 13-14, 2025.
Findings
The facility was found to have multiple violations related to personal care home regulations, including contract signatures, resident personal equipment, sanitary conditions, furnace inspection and cleaning, fire extinguisher inspection, smoking area guidelines, medication labeling and records, staff training, record confidentiality, abuse, and following prescriber's orders. Plans of correction were submitted and some violations were corrected at the time of inspection, while others had directed or ongoing corrective actions.
Citations (14)
The resident-home contract was not signed by the resident due to cognitive deficits, requiring audits of resident contracts for signature validation.
A bedside mobility device was not securely attached and a piece was missing, which was repaired at the time of inspection.
No paper towels or other hand drying options were available at sinks in the memory care activity room, bistro, and resident laundry rooms, which was corrected immediately.
The home was unable to provide documentation that multiple natural gas furnaces had been inspected or cleaned within the last year, but inspections and cleanings were completed during the survey.
Fire extinguishers in the secured dementia care unit mechanical room were last inspected in August 2024 and were inspected and tagged during the survey.
More than five cigarette butts were found on the ground in front of the home's dumpsters, which is not a designated smoking area; the cigarette butts were discarded and staff educated.
Two bottles of OTC tablets belonging to residents were not labeled with the resident's name, which was corrected during the inspection.
Resident medication administration records did not indicate the diagnosis or purpose for several prescribed medications, requiring audits and pharmacy communication.
A direct care staff person in the secured dementia care unit had only 5 hours of training in dementia care during the 2024 calendar year instead of the required 6 hours.
Electronic medication administration record (eMAR) terminal was unlocked and unattended with accessible resident information, which was immediately secured.
A resident was assessed to have a stage II pressure ulcer and required assistance with bladder and bowel incontinence, but the assessment and support plan indicated some neglect and inadequate care.
Expired and opened medications were found in the medication cart, which were disposed of and reordered by the Health Care Specialist.
The pharmacy label for certain residents' medications did not include instructions for administration, which was corrected and staff educated.
A medication error occurred when a resident's medication was not administered as prescribed due to vital sign parameters, and the staff member was counseled.
Report Facts
Residents Served: 75
Secured Dementia Care Unit Residents Served: 24
Hospice Current Residents: 5
Resident Age 60 or Older: 75
Residents with Mobility Need: 25
Inspection Report — Jun 18, 2025
Follow-Up
Date: Jun 18, 2025
Visit Reason
The inspection visit on 06/18/2025 was a partial, unannounced follow-up to review the submitted plan of correction for previously identified deficiencies.
Findings
The facility was found to have implemented the plan of correction fully, addressing sanitary condition issues related to a resident's incontinence and housekeeping practices. The inspection included audits, cleaning, maintenance repairs, staff education, and updated care plans.
Citations (1)
Sanitary conditions were not maintained due to a resident's increased incontinence, resulting in urine odor and soiled paper towels and clothing in the resident's room.
Report Facts
Residents Served: 79
Residents Served in Secured Dementia Care Unit: 29
Current Hospice Residents: 5
Residents Diagnosed with Mental Illness: 30
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 30
Residents with Physical Disability: 2
Inspection Report — May 8, 2025
Follow-Up
Date: May 8, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted to review the implementation of a previously submitted plan of correction for the facility.
Findings
The inspection found multiple deficiencies including unlocked medication carts exposing confidential resident information, failure to assess residents' ability to consent to relationships in the secured dementia care unit, lack of required staff training on medication self-administration and resident needs, lint accumulation in dryers posing fire hazards, and incomplete medical evaluations for residents admitted to the secured dementia care unit. All deficiencies had plans of correction accepted and were implemented by July 2025.
Citations (5)
Medication carts were left unlocked and unattended, exposing confidential resident information on laptops.
Residents in the secured dementia care unit were not assessed for their ability to consent to relationships, leading to inappropriate supervision and monitoring.
Several staff members did not receive required training in medication self-administration and instruction on meeting resident needs during the 2024 training year.
Lint accumulation was found in one of the dryers, increasing fire hazard risk.
A resident's medical evaluation did not include required diagnosis and need for secured dementia care unit placement.
Report Facts
Residents Served: 77
Residents Served in Secured Dementia Care Unit: 31
Current Hospice Residents: 6
Residents Age 60 or Older: 77
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 37
Staff Total Daily: 114
Staff Waking: 86
Number of dryers in home: 10
Inspection Report — Apr 16, 2025
Complaint Investigation
Date: Apr 16, 2025
Visit Reason
The inspection was conducted as a complaint investigation and incident review following allegations of abuse, elopement, and other regulatory concerns at the facility.
Complaint Details
The visit was complaint-related with substantiated findings including late incident reporting, resident elopement, abuse, and safety violations.
Findings
The inspection identified multiple deficiencies including late reporting of incidents, resident elopement, abuse, unsecured poisonous materials, unsanitary conditions, malfunctioning egress doors, improper medication storage, incomplete resident assessments, and inadequate posting of locking device instructions. Plans of correction were accepted and implemented with ongoing compliance monitoring scheduled.
Citations (12)
Late reporting of written incident reports to the Department.
Resident abuse including failure to prevent elopement and inappropriate sexual contact between residents.
Poisonous materials were unlocked and accessible to residents not assessed as capable of safe use.
Unsanitary bathroom conditions including feces on toilet and trash can.
Door in Secure Dementia Care Unit with malfunctioning code box preventing immediate egress.
Designated smoking area had cigarette butts outside exit door; resident observed smoking in courtyard.
Medications and syringes were unlocked and accessible in resident rooms.
Expired denture cleaner found in resident bedroom.
Resident assessments did not include ongoing wandering, exit-seeking behaviors, or use of assistive devices.
Directions for operating key-locking devices were not conspicuously posted near Secure Dementia Care Unit door.
Door beside kitchenette in Secure Dementia Care Unit did not consistently latch closed.
Correction tape used on resident preadmission screening and progress notes, violating record entry requirements.
Report Facts
Residents Served: 79
Residents Served in Memory Care Unit: 30
Current Hospice Residents: 8
Residents Age 60 or Older: 79
Residents with Intellectual Disability: 1
Residents with Mobility Need: 33
Staff Total Daily: 112
Staff Waking: 84
Inspection Report — Feb 25, 2025
Renewal
Date: Feb 25, 2025
Visit Reason
The inspection was conducted as part of a renewal, complaint, and incident investigation at Legend Personal Care and Memory Care of Lancaster.
Complaint Details
Complaint investigation revealed incidents of resident abuse, elopement, failure to report incidents timely, and unsafe conditions. Some plans of correction were not accepted due to inability to correct or late reporting.
Findings
The facility was found to have multiple violations including failure to post current license inspection summaries, delayed access to requested records, failure to report suspected resident abuse and incidents timely, resident abuse incidents, medication administration errors, training deficiencies, fire safety issues, and unsafe storage of poisonous materials. Plans of correction were submitted with some deficiencies not yet implemented.
Citations (18)
Failure to post the most recent renewal license inspection summary and partial inspection summaries in a conspicuous and public place.
Delayed provision of census, administrator records, fire drill records, medication training records, and reportable incidents to Department agents.
Failure to immediately report suspected resident abuse incidents to local police and area agency on aging.
Failure to report an emergency transfer to hospital with allegation of neglect to the Department.
Resident records were left unlocked and accessible with resident information visible on computer screens and medications accessible.
Resident abuse incidents including inappropriate touching and physical harm were documented with inadequate reporting and follow-up.
Direct care staff did not receive required annual training on medication administration, resident needs, mental illness, intellectual disability, and fire safety.
Emergency telephone numbers were not posted by telephones in the Secure Dementia Care Unit.
Lint accumulation found in dryer lint traps in laundry areas.
Lack of documentation for annual furnace inspection and cleaning.
Fire drill evacuation time exceeded the home's maximum evacuation time.
Smoking occurred in non-designated areas and cigarette butts were scattered outside the building.
First aid kit in wheelchair van lacked antiseptic.
Medications found in the home without current orders or discontinued medications present.
Medication labels did not match physician orders.
Blood glucose readings documented on MAR were not present in resident glucometers.
Multiple medications were not administered as prescribed, including missed doses and unavailable medications.
Staff administering medications were not properly certified or trained as required.
Report Facts
Residents Served: 90
Residents Served in Secured Dementia Care Unit: 36
Staffing Hours: 128
Waking Staff: 96
Fine Amount: 385
Fine Per Resident Per Day: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed letter regarding provisional license and enforcement actions. |
| Staff Member A | Witnessed resident abuse and involved in incident on 4/2/25. | |
| Staff Member B | Witnessed resident abuse, trained for medication administration without proper certification. | |
| Staff Member C | Involved in resident abuse incident on 4/2/25. | |
| Staff Member D | Involved in resident abuse incident and medication administration training deficiencies. | |
| Staff Member E | Witnessed resident abuse incident. | |
| Staff Member G | Observed vaping in non-designated smoking area. | |
| Staff Member H | Initially certified for medication administration but lacked annual training and observations. | |
| Staff Member I | Administered medications without documentation of initial certification. | |
| Staff Member J | Administered medications without documentation of initial certification. | |
| Staff Member K | Administered medications without documentation of initial certification. | |
| Administrator | Named in multiple findings related to education, incident reporting, and compliance monitoring. | |
| Regional Director of Operations | Named in plans of correction and education related to compliance. | |
| Assistant Healthcare Director | Named in medication administration and incident reporting findings. | |
| Maintenance Director | Named in findings related to fire safety, furnace inspection, door locking mechanisms, and lint removal. |
Inspection Report — Dec 11, 2024
Complaint Investigation
Date: Dec 11, 2024
Visit Reason
The inspection was conducted as a complaint investigation and incident review, as indicated by the reason stated in the inspection information section.
Complaint Details
The visit was complaint-related as indicated by the inspection reason. Specific complaints involved medication administration, resident assessments, and admission documentation.
Findings
The inspection identified multiple deficiencies including failure to follow prescriber's medication orders, incomplete preadmission screening documentation, failure to conduct additional assessments after significant resident condition changes, and lack of documentation for resident and designated person non-objection to admission to the secured dementia care unit.
Citations (4)
Failure to follow prescriber's orders by not administering medications at prescribed times for residents.
Preadmission screening form did not include a determination that the needs of the resident can be met by the services provided by the home.
Failure to add a significant change when updating resident assessment and complete additional assessment after determining need for memory care placement.
No documentation that the resident and the resident's designated person have not objected to admission or transfer to the secured dementia care unit.
Report Facts
Residents Served: 86
Residents Served in Secured Dementia Care Unit: 34
Current Hospice Residents: 7
Residents Age 60 or Older: 86
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 38
Inspection Report — Oct 3, 2024
Follow-Up
Date: Oct 3, 2024
Visit Reason
The inspection was conducted as a complaint investigation and incident review, including a follow-up on the submitted plan of correction.
Complaint Details
The inspection was triggered by a complaint and incident involving resident injury due to alleged abuse.
Findings
The facility was found to have multiple deficiencies including resident abuse resulting in injury, inadequate fire safety orientation for new staff, incomplete medical evaluations, medication storage issues, and incomplete resident support plans. The submitted plan of correction was accepted and fully implemented by November 6, 2024.
Citations (5)
Resident was found sitting on the floor with a bloody nose after being struck, resulting in a nasal fracture.
Several staff did not receive required fire safety and emergency preparedness orientation prior to or during their first work day.
Resident medical evaluations lacked required information such as height, weight, vital signs, body positioning/movement, and medical professional's name.
Medication prescribed to a resident was not available for administration due to backorder.
Resident support plans did not include necessary information about use and maintenance of Foley leg bag and assistance needs with toileting hygiene and transfers.
Report Facts
Residents Served: 92
Secured Dementia Care Unit Residents Served: 35
Current Hospice Residents: 5
Residents Age 60 or Older: 92
Residents with Intellectual Disability: 1
Residents with Mobility Need: 42
Total Daily Staff: 134
Waking Staff: 101
Inspection Report — May 30, 2024
Complaint Investigation
Date: May 30, 2024
Visit Reason
The inspection was conducted as a complaint, incident, and interim review to assess compliance with applicable regulations at the facility.
Complaint Details
The inspection was complaint-related, triggered by a complaint, incident, and interim review. Multiple repeated violations were noted from previous inspection dates 9/27/23, 8/29/23, and 6/6/23.
Findings
Multiple areas of non-compliance were found including failure to report incidents timely, incomplete medical evaluations, discrepancies in medication administration records, failure to follow prescriber's orders, delayed resident assessments, and delayed development of admission support plans. Several violations were noted as repeated from prior inspections.
Citations (6)
Failure to report an incident to the Department within 24 hours as required.
Resident's initial medical evaluation was not completed within the required timeframe relative to admission.
Discrepancies observed between resident and medication administration record (MAR) including missing blood sugar readings.
Failure to follow prescriber's orders with multiple medications not administered due to unavailability.
Resident's initial assessment was not completed within 15 days of admission.
Resident's initial support plan for Secure Dementia Care Unit admission was not completed within 72 hours as required.
Report Facts
Residents Served: 77
Residents in Secured Dementia Care Unit: 27
Current Hospice Residents: 7
Residents Age 60 or Older: 77
Residents with Mental Illness: 1
Residents with Mobility Need: 33
Total Daily Staff: 110
Waking Staff: 83
Inspection Report — Apr 9, 2024
Follow-Up
Date: Apr 9, 2024
Visit Reason
The inspection was a full, unannounced visit conducted on 04/09/2024 for renewal, complaint, incident, and interim review purposes.
Findings
The facility had multiple deficiencies including failure to report incidents timely, inadequate emergency food supply, missed fire drills and incomplete fire drill records, failure to secure medical care timely, staff training deficiencies, vehicle registration lapse, medication administration record errors, incomplete preadmission screening and assessments, and incomplete support plans. Plans of correction were accepted and implemented with ongoing monitoring.
Citations (16)
Failure to report incidents to the department within 24 hours including gas odor evacuation and unwitnessed falls with injuries.
Inadequate emergency food supply to sustain residents for 3 days.
Unannounced fire drill not held during the month of February 2024.
Fire drill records missing seconds for drills conducted on 12/30/23, 3/20/24, and 4/4/24.
Fire drill during sleeping hours not conducted within required 6 month period.
Fire drills routinely held between 11:00 am and 5:26 pm, not varying days/times as required.
Failure to assist resident to secure medical care for missing dentures and chewing difficulties.
Staff person transported resident without required direct care certification.
Vehicle registration expired and vehicle used to transport residents before renewal.
Medication administration records missing date, time, and staff initials for administration of insulin and cream.
Resident admitted without completed preadmission screening form.
Resident admitted without initial assessment completed within 15 days.
Resident had additional assessment overdue prior to annual assessment.
Resident support plan did not address dietary or dental needs.
Resident admitted to secured dementia care unit without timely cognitive preadmission screening.
Resident admitted to secured dementia care unit without support plan developed within 72 hours.
Report Facts
Residents Served: 80
Residents Served in Memory Care: 30
Current Residents in Hospice: 3
Total Daily Staff: 113
Waking Staff: 85
Residents Served: 77
Residents Served in Memory Care: 27
Current Residents in Hospice: 7
Total Daily Staff: 110
Waking Staff: 83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed correspondence related to plan of correction implementation. |
| Robert Mueller | Fire Life Safety Solutions Instructor | Scheduled to provide fire safety expert training to Maintenance Director. |
Inspection Report — Jan 23, 2024
Follow-Up
Date: Jan 23, 2024
Visit Reason
The inspection was a follow-up visit triggered by a complaint and incident review to verify the implementation of a previously submitted plan of correction.
Complaint Details
The inspection was complaint-related and incident-driven, with an exit conference held on 01/24/2024. The plan of correction was accepted and fully implemented by 07/03/2024.
Findings
The facility was found to have multiple repeat violations including resident abuse, medication administration errors, vehicle documentation issues, and deficiencies in resident support plans. The submitted plan of correction was determined to be fully implemented as of the follow-up date.
Citations (5)
Resident verbal and physical abuse incidents observed, including hitting and use of a chair as a weapon.
Home's vehicle used to transport residents lacked current inspection documentation.
Medication cart was found unlocked and unattended with keys left in the lock.
Medication was administered to the wrong resident and not according to prescription orders.
Resident support plans did not reflect behavioral issues or plans to meet service needs.
Report Facts
Residents Served: 78
Memory Care Residents Served: 29
Current Hospice Residents: 2
Residents with Mobility Need: 31
Residents 60 Years or Older: 77
Residents Diagnosed with Intellectual Disability: 1
Total Daily Staff: 109
Waking Staff: 82
Inspection Report — Jan 11, 2024
Follow-Up
Date: Jan 11, 2024
Visit Reason
The inspection visit was a follow-up to verify the implementation of a previously submitted plan of correction related to medication administration and glucometer reading discrepancies.
Findings
The Pennsylvania Department of Human Services determined that the submitted plan of correction was fully implemented, ensuring compliance with safe medication storage and administration procedures.
Citations (1)
Discrepancies between glucometer readings and Medication Administration Record (MAR) entries for Resident #1, including multiple entries of the same readings and readings differing between the glucometer and MAR.
Report Facts
Residents Served: 77
Memory Care Residents Served: 29
Current Hospice Residents: 2
Residents Age 60 or Older: 77
Residents with Intellectual Disability: 1
Residents with Mobility Need: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Healthcare Director | Responsible for auditing glucometer daily and overseeing plan of correction implementation | |
| Diabetic Trainer | Provided mandatory diabetic training for medication associates |
Inspection Report — Jun 6, 2023
Enforcement
Date: Jun 6, 2023
Visit Reason
The inspection was conducted as a renewal and complaint investigation of Legend Personal Care and Memory Care of Lancaster.
Complaint Details
The complaint involved allegations of resident abuse, medication errors, failure to report incidents timely, and inadequate care. Multiple abuse incidents between residents were documented. Several medication administration errors and refusals were not reported to prescribers. The home failed to report an incident of verbal abuse to the Department. Repeated violations from prior inspections were noted.
Findings
Multiple violations were found including failure to post current license and inspection summaries, delayed incident reporting, incomplete resident contracts, staff hiring and training deficiencies, unsafe storage of poisonous materials, sanitary issues, medication administration errors, and abuse incidents. Several violations were repeated from prior inspections.
Citations (30)
The home's current license and inspection summaries were not posted in a conspicuous and public place.
Incident of resident injury was not reported timely to the Department.
Resident-home contracts were incomplete or unsigned by required parties.
Staff criminal background checks were not completed timely.
Insufficient staff with current CPR and First Aid training on multiple shifts.
Poisonous materials were unlocked and accessible to residents in the secure dementia care unit.
Trash receptacles in kitchens and bathrooms were uncovered and unattended.
Hot water temperatures exceeded 120°F in multiple locations accessible to residents.
Food requiring refrigeration was stored without a thermometer in the freezer.
Outdated or dented food cans were found in the kitchen storage.
Resident's pet did not have a current rabies vaccination certificate on file.
Furnaces were not inspected or cleaned annually as required.
Unannounced fire drills were not held monthly and during sleeping hours as required.
Residents did not evacuate to designated meeting places during fire drills.
Resident smoked in a non-smoking area causing burn damage.
First aid kits in resident transport vehicles lacked required items.
Medication labels did not match prescriber orders.
Medication storage and documentation procedures were not properly followed.
Medication administration records lacked required signatures and documentation.
Staff administered medications without completing required training and competency testing.
Preadmission screening forms were incomplete or not timely.
Resident assessments and support plans were incomplete, unsigned, or not timely.
Key-locking devices did not have current codes or proper signage.
Controlled substance logs were unsecured and accessible.
Residents were subjected to abuse and neglect, including physical altercations and verbal mistreatment.
Medication errors were not reported timely to the Department or prescribers.
Medication refusals were not reported to prescribers as required.
Medication carts were found unlocked and unattended.
Residents did not have access to their bedrooms at all times; doors were locked.
Sanitary conditions were not maintained; feces was found smeared on hallway carpet.
Report Facts
Number of residents served: 73
Residents served in secured dementia care unit: 31
Residents served in secured dementia care unit: 27
Staffing hours: 112
Waking staff hours: 84
Staffing hours: 103
Waking staff hours: 77
Staffing hours: 104
Waking staff hours: 78
Fine amount per violation: 365
Number of violations fined: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary, Office of Long-term Living | Signed enforcement letter dated December 22, 2023 |
| Residence Director | Named in multiple findings related to plan of correction implementation, incident reporting, and staff training | |
| Healthcare Director | Named in multiple findings related to medication errors, staff training, and plan of correction implementation | |
| Assistant Healthcare Director | Named in findings related to medication administration, support plan compliance, and staff training | |
| Regional Director of Operations | Facilitated training related to abuse reporting and plan of correction | |
| Maintenance Director | Named in findings related to correction of hot water temperature, furnace inspection, and securing poisonous materials | |
| Sous Chef | Corrected outdated food violation | |
| Staff Person A | Named in abuse complaint and background check violation | |
| Staff Person B | Named in abuse complaint, background check violation, and termination | |
| Staff Person C | Named in medication administration training violation | |
| Staff Person D | Named in medication administration training violation | |
| Staff Person E | Named in diabetic training violation | |
| Staff Person F | Named in diabetic training violation |
Inspection Report — Mar 14, 2023
Follow-Up
Date: Mar 14, 2023
Visit Reason
The inspection was conducted as a follow-up to a complaint investigation to verify the implementation of the submitted plan of correction.
Complaint Details
The visit was complaint-related. The complaint involved allegations of resident abuse and failure to report incidents timely. The plan of correction was submitted and fully implemented as verified by the follow-up inspection.
Findings
The submitted plan of correction was found to be fully implemented, with continued compliance required. The report details deficiencies related to resident abuse reporting and incident reporting, all of which have been addressed with corrective actions and staff training.
Citations (3)
Failure to complete and send the Mandatory ACT 13 Form reporting an allegation of abuse after an altercation between residents.
Failure to report an incident involving a resident exhibiting behavior resulting in 911 being called and psychiatric evaluation within 24 hours to the department.
Resident abuse involving a resident forcibly kicking another resident, with inadequate monitoring and reporting.
Report Facts
Residents Served: 81
Secured Dementia Care Unit Residents Served: 34
Current Hospice Residents: 6
Total Daily Staff: 82
Waking Staff: 62
Inspection Report — Aug 24, 2022
Follow-Up
Date: Aug 24, 2022
Visit Reason
The visit was a partial, unannounced follow-up inspection conducted on 08/24/2022 and 08/26/2022 to review the facility's compliance with previously identified deficiencies and the implementation of the submitted plan of correction.
Findings
The inspection found multiple repeat violations related to trash receptacles, emergency telephone numbers, food protection and storage, medication storage and administration, and documentation of medication refusals. The facility had implemented corrective actions including staff re-education, posting emergency numbers, and weekly audits, with the plan of correction fully implemented as of 02/13/2023.
Citations (10)
Trash in kitchens and bathrooms was kept in uncovered trash receptacles allowing penetration of insects and rodents.
Emergency telephone numbers for nearest hospital and fire department were not posted on or by telephones in residents' rooms.
Food was not protected from contamination; uncovered tray of salmon burgers found in walk-in refrigerator.
Food was stored on the floor; an open 50 pound bag of potatoes was stored on the floor in the dry storage area.
Leftover food was unlabeled and undated in the walk-in and sandwich refrigerators.
Medications stored in residents' rooms were unlocked and unattended, not kept in a locked, secure location.
One Touch Glucometer was not calibrated to the correct date and time.
Medication cart lacked adequate supply of testing strips for residents with blood sugar readings prescribed.
Prescription medications found in residents' rooms were not prescribed by an authorized prescriber.
Refusals of prescribed medications by Resident #6 were not documented or reported to the prescriber within 24 hours.
Report Facts
Residents Served: 70
Secured Dementia Care Unit Residents Served: 23
Current Hospice Residents: 2
Waking Staff: 76
Total Daily Staff: 101
Residents Age 60 or Older: 70
Residents with Mobility Need: 31
Inspection Report — May 3, 2022
Renewal
Date: May 3, 2022
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal, complaint, and incident review purposes at Legend Personal Care and Memory Care of Lancaster.
Findings
The inspection identified multiple deficiencies related to staff hiring and training, medication administration, resident assessments, support plans, emergency preparedness, food storage, and facility maintenance. Plans of correction were accepted and implemented with ongoing monitoring and audits.
Citations (29)
Staff member A was hired without timely completion of PA criminal background check.
Direct Care Staff Person B lacked documented high school diploma, GED, or nurse aide registry status.
Insufficient CPR/First Aid certified staff present during specified times.
Staff Persons A and C did not receive required first day fire safety orientation.
Staff Person A had not completed required orientation on resident rights, emergency medical plan, abuse reporting, and incident reporting within 40 hours.
Direct Care Staff Person C provided unsupervised ADL services without completing required training and competency test.
Three uncovered trash cans found in kitchen.
Emergency telephone numbers missing on or by telephones in library and rooms 106 and 134.
First aid kits missing tweezers and thermometers.
Resident 1's bedroom carpet and wall stained and in need of cleaning.
Uncovered bag of bread crumbs stored in dry storage area.
Unlabeled and undated leftover food containers in walk-in refrigerator.
Dryer ducts had not been cleaned since October 2020.
Emergency procedures do not specify actions when smoke detectors or fire alarms are inoperable.
Loose pills found in medication carts.
Resident 2's medication administration record did not indicate insulin dosage.
Medication administration records missing staff initials for multiple residents on various dates.
Resident 1 refused medication without documentation of prescriber notification.
Staff persons D and B administered medications without completing required medication administration course.
Resident 2's preadmission screening form was completed after admission date.
Resident 2's assessment was not completed within 15 days of admission.
Enabler bars observed on residents' beds without documentation in support plans.
Resident 2 and 4's cognitive preadmission screening forms were not completed within 72 hours prior to admission to secured dementia care unit.
Residents 2, 3, and 4 lacked documentation of no objection to admission to secured dementia care unit.
Resident 4's initial support plan was not completed within 72 hours of admission to secured dementia care unit.
Bottles of pork red sauce and spaghetti sauce in walk-in refrigerator were not properly sealed.
Resident 6's medications were unlocked and accessible in resident's bedroom.
Glucometers for Residents 1 and 2 were not calibrated correctly and glucometer readings were incorrectly documented.
Residents 1 and 5 did not sign their support plans; assessor did not sign Resident 5's support plan.
Report Facts
Residents served: 56
Staffing hours: 85
Waking staff: 64
Secured dementia care residents served: 20
Hospice residents: 2
Residents 60 years or older: 56
Residents with mental illness: 4
Residents with intellectual disability: 2
Residents with mobility needs: 29
Residents with physical disability: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in violation for incomplete criminal background check and orientation deficiencies | |
| Direct Care Staff Person B | Named in violation for lacking documented qualifications and medication administration without required course | |
| Staff Person C | Named in violation for lack of training and orientation, and providing unsupervised ADL services without required training | |
| Staff Person D | Named in violation for administering medications without completing required medication administration course | |
| Resident 1 | Named in medication administration and support plan signature violations | |
| Resident 2 | Named in medication administration, preadmission screening, and secured dementia care unit documentation violations | |
| Resident 3 | Named in medication administration and secured dementia care unit documentation violations | |
| Resident 4 | Named in assessment, support plan, and secured dementia care unit documentation violations | |
| Resident 5 | Named in support plan signature violation | |
| Resident 6 | Named in medication storage violation | |
| Resident 7 | Named in support plan documentation violation | |
| Resident 8 | Named in support plan documentation violation |
Inspection Report — Mar 15, 2022
Complaint Investigation
Date: Mar 15, 2022
Visit Reason
The inspection was conducted as a complaint investigation following allegations of resident abuse and other regulatory concerns at Legend Personal Care and Memory Care of Lancaster.
Complaint Details
The complaint involved allegations of resident abuse where Resident 1 was observed punching Resident 2, and Resident 3 was observed pushing and kicking Resident 1. The facility failed to report this incident immediately as required.
Findings
The inspection identified multiple deficiencies including failure to timely report resident abuse, insufficient staffing during night hours, incomplete or unsigned resident contracts and support plans, and incomplete medical evaluations and assessments. Plans of correction were directed with specific deadlines for compliance.
Citations (10)
Failure to immediately report suspected resident abuse to the local area agency on aging protective services unit.
Resident-home contracts for several residents were not signed by the residents.
Insufficient staffing during night hours to meet the needs of residents, especially those with mobility needs.
Medical evaluation for a resident was not completed within required timeframe.
Resident medical evaluation did not include body positioning and movement stimulation.
Preadmission screening form was not completed for a resident prior to admission.
Initial assessments were not completed within 15 days of admission for some residents.
Annual assessments for some residents were not completed timely.
Support plan for a resident was not signed by the assessor.
Support plan for a resident was not signed by the resident nor was there a notation of refusal or inability to sign.
Report Facts
Residents Served: 63
Residents Served in Dementia Unit: 21
Residents with Mobility Need: 24
Staffing: 2
Directed Completion Date: Jul 29, 2022
Inspection Report — Jan 26, 2022
Renewal
Date: Jan 26, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing for the facility.
Findings
No regulatory citations were identified as a result of this inspection.
Notice — Sep 24, 2021
Date: Sep 24, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for Legend Personal Care and Memory Care of Lancaster, confirming receipt of the renewal application and advising of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it is a licensing and renewal notification letter along with a certificate of compliance indicating authorized operation and capacity limits.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report — Jul 22, 2021
Complaint Investigation
Date: Jul 22, 2021
Visit Reason
The inspection was conducted as a complaint investigation at the facility.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 70
Secured Dementia Care Unit Residents Served: 26
Current Hospice Residents: 3
Residents Age 60 or Older: 70
Residents with Mobility Need: 28
Notice — Nov 18, 2020
Date: Nov 18, 2020
Visit Reason
The document serves as a renewal notification and issuance of a regular license for Legend Personal Care and Memory Care of Lancaster following receipt of a renewal application.
Findings
The Department confirms receipt of the renewal application and states that an onsite inspection will be conducted within the next twelve months as required by regulation. Enforcement action may be taken if non-compliance is found during the inspection.
Report Facts
Inspection Report — Oct 17, 2019
Renewal
Date: Oct 17, 2019
Visit Reason
The inspection was conducted as a renewal visit to review compliance and verify the submitted plan of correction.
Findings
The facility had multiple deficiencies related to food storage, medication security and labeling, storage procedures, following prescriber's orders, and support plan signatures. The submitted plan of correction was fully implemented as of November 26, 2019.
Citations (6)
103g Food shall be stored in closed or sealed containers. A bag of dried apple rings and a box of sprinkles in the kitchen pantry were not sealed.
183b Prescription medications and syringes shall be kept locked. Resident 1 had an unsecured bottle of Lantanoprost and was not assessed as capable to self-administer it.
184b OTC medications and CAM must be labeled with the resident's name. Multiple medications in the medication cart were not labeled to identify the resident using them.
185a The home shall implement procedures for safe use of medications and equipment. Glucometers had incorrect readings and programming errors affecting Residents 2, 3, and 4.
187d The home shall follow prescriber's directions. Resident 4's blood sugar testing was not completed as ordered and Resident 5 did not receive prescribed medications during a specified period.
227g Individuals involved in support plan development shall sign and date the plan. Family members of Residents 6 and 7 did not sign or document refusal to sign support plans.
Report Facts
Residents Served: 70
Residents Served in Dementia Unit: 21
Hospice Current Residents: 1
Resident Support Staff: 0
Total Daily Staff: 91
Waking Staff: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Mackley | Administrator | Named in relation to plan of correction signatures and approval |
Notice — Sep 24, 2019
Date: Sep 24, 2019
Visit Reason
This document serves as a renewal notification and license issuance for Legend Personal Care and Memory Care of Lancaster, confirming the facility's authorized capacity and informing about the requirement for annual onsite inspections.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license and outlines the Department's obligation to conduct annual inspections.
Report Facts
Inspection Report — Nov 27, 2018
Renewal
Date: Nov 27, 2018
Visit Reason
The inspection was conducted as a renewal inspection of Legend Personal Care and Memory Care of Lancaster on November 27 and 28, 2018.
Findings
The facility was found to be in compliance with 55 Pa.Code Chapter 2600 after corrections were made. One violation was cited related to the failure to properly store blood sugar measurements in the resident's glucometer memory.
Citations (1)
REGULATION 55 Pa.Code §2600: The home failed to ensure blood sugar measurements were stored in the resident's glucometer memory, as documented for Resident #1 on multiple dates. The glucometer was found to be incorrectly set and was subsequently replaced and monitored.
Report Facts
Number of Residents Served: 52
Number of Current Hospice Residents: 3
Number of Hospice Residents in past year: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Mackley | Administrator | Named as facility administrator on page 2 and signed plan of correction on page 3. |
| Israel Springs | Department representative present during inspection on 11/27/2018 and 11/28/2018. | |
| Michael Showers | Department representative present during inspection on 11/27/2018 and 11/28/2018. |
Inspection Report — Oct 25, 2018
Complaint Investigation
Date: Oct 25, 2018
Visit Reason
The inspection was conducted as a complaint investigation at Legend Personal Care and Memory Care of Lancaster.
Complaint Details
The inspection was triggered by a complaint. No substantiation status is explicitly stated.
Findings
Violations of 55 Pa.Code Chapter 2600 were found related to the condition of the bedrooms, specifically a stained carpet with urine odor. A plan of correction was submitted to address these issues.
Citations (1)
55 Pa.Code §2600.101(o) - The bedrooms must have walls, floors and ceilings, which are finished, clean and in good repair. The carpet in bedroom 142 is stained and smells of urine around a recliner in the seating area.
Report Facts
Number of Residents Served: 56
Number of Residents Served in Secured Dementia Care Unit: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Mackley | Residence Director | Named as Administrator and signed the plan of correction. |
| Laura Heemer | Department representative conducting the inspection. |
Notice — Sep 24, 2018
Date: Sep 24, 2018
Visit Reason
The document acknowledges receipt of a renewal application to operate a Personal Care Home and informs the facility that an annual onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
No inspection findings are reported in this document. It serves as a license renewal confirmation and notification of upcoming inspection requirements.
Report Facts
Inspection Report — Apr 3, 2018
Renewal
Date: Apr 3, 2018
Visit Reason
The document is a renewal of the facility license due to a recent name change from SIGNATURE SENIOR LIVING LANCASTER PERSONAL AND MEMORY CARE to LEGEND PERSONAL CARE AND MEMORY CARE OF LANCASTER.
Findings
A new license is issued under the authority of 55 Pa.Code Chapter 2600 for Personal Care Homes reflecting the name change and confirming the licensed capacity.
Report Facts
Inspection Report — Dec 18, 2017
Renewal
Date: Dec 18, 2017
Visit Reason
The inspection was a renewal licensing inspection conducted on December 18, 2017, December 19, 2017, January 23, 2018, and January 29, 2018 for Signature Senior Living Lancaster Personal & Memory Care Community.
Complaint Details
A written complaint was filed on 11/28/2017 regarding call bell response times. The complaint was addressed but the violation cited was due to a previous administration's error in retaining a copy of the response to the resident.
Findings
The inspection found multiple violations related to complaint investigation response, sanitary conditions, hot water temperature, fire hazard prevention, medication error documentation, and exit door signage. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (6)
55 Pa.Code 2600.44(f) requires a written decision explaining investigation findings and actions after a complaint. The home failed to provide Resident #4 a written decision regarding call bell response times complaint.
55 Pa.Code 2600.85(a) requires sanitary conditions be maintained. Staff failed to follow best practices by sharing glucometers between residents instead of using individual labeled devices.
55 Pa.Code 2600.89(b) prohibits hot water temperatures exceeding 120°F in resident-accessible areas. Water temperatures of 127°F and 128°F were found in two locations.
55 Pa.Code 2600.105(g)(1) requires lint removal from dryer lint traps to reduce fire risk. An accumulation of lint was found in a dryer lint screen in the staff laundry room.
55 Pa.Code 2600.183(c) requires documentation of medication errors and prescriber responses in resident records. Resident #2's medication error documentation and prescriber response were missing.
55 Pa.Code 2600.233(c) requires conspicuous posting of directions for exit door locking devices in the Secured Dementia Care Unit. The correct code for operating the home's locking mechanism was not posted near the exit doors.
Report Facts
Number of Residents Served: 56
Number of Residents Served in Secured Dementia Care Unit: 15
Number of Current Hospice Residents: 0
Number of Hospice Residents in Past Year: 4
Residents Age 60 or Older: 55
Residents with Mobility Need: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Dugas | Legal Entity Representative | Signed plan of correction pages |
| Laura Heemer | Inspector | Conducted inspection on site |
| Jason McCloskey | Inspector | Conducted inspection on site |
Inspection Report — Oct 17, 2017
Complaint Investigation
Date: Oct 17, 2017
Visit Reason
The inspection was conducted as a complaint investigation following allegations related to medication administration and medical evaluations at Signature Senior Living Lancaster Personal & Memory Care.
Complaint Details
The inspection was complaint-driven and substantiated violations related to medication administration errors and medical evaluation deficiencies.
Findings
The inspection found multiple violations including failure to report medication errors, incomplete medical evaluations within required timeframes, and failure to follow prescriber directions for medication administration.
Citations (3)
55 Pa.Code §2600.16(c): The home failed to report medication errors involving Residents #1 and #2 to the Department as required within 24 hours.
55 Pa.Code §2600.141(a)(1): Residents #3 and #4 did not have medical evaluations completed within the required timeframe prior to or shortly after admission.
55 Pa.Code §2600.187(d): Resident #3 did not receive prescribed Travatan Z eye drops on September 27, 2017, because the medication was not available in the home.
Report Facts
Number of Residents Served: 45
Number of Residents Served in Secured Dementia Care Unit: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Krista Funk | Executive Director | Named in plan of correction signatures and responsible for corrective actions |
Notice — Oct 11, 2017
Date: Oct 11, 2017
Visit Reason
This document serves as a renewal notice and license issuance for Signature Senior Living Lancaster Personal & Memory Care Community, confirming the facility's authorized capacity and renewal application.
Findings
The document confirms the facility's license renewal and authorized capacity of 100 residents, including a secure dementia care unit capacity of 40. It states the Department's requirement to conduct an annual onsite inspection within the next twelve months.
Report Facts
Notice — Sep 11, 2017
Date: Sep 11, 2017
Visit Reason
The document is a response to a waiver request related to qualifications for direct care staff persons under 55 Pa.Code § 2600.54(a).
Findings
The Department determined that the submitted educational documentation is comparable to a high school diploma from the United States, so a waiver is not needed. The facility must keep a copy of the educational documentation and this determination.
Report Facts
Waiver request: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Kachmar | Regulatory Licensing Manager | Signed the waiver determination letter. |
Inspection Report — Jan 4, 2017
Original Licensing
Date: Jan 4, 2017
Visit Reason
The document is a licensing inspection report for Signature Senior Living Lancaster Personal and Memory Care Community, assessing compliance for initial licensure.
Findings
The facility was found to be in substantial compliance with applicable regulations but the licensing inspector was unable to complete a full inspection because the home was new and not yet serving four or more residents.
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