Inspection Reports for
Oxford Crossings
310 E Winchester Ave, Langhorne, PA 19047, United States, PA, 19047
Back to Facility Profile22 Reports
Notice — Aug 22, 2026
Date: Aug 22, 2026
Visit Reason
The document serves to notify the facility that a waiver request for direct care staff qualifications under 55 Pa.Code § 2600.54(a)(2) has been granted.
Findings
The waiver is granted with conditions including documentation of education equivalency and annual review during the facility's annual inspection to ensure compliance.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Jul 21, 2026
Monitoring
Date: Jul 21, 2026
Visit Reason
The inspection was a monitoring visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing to verify compliance and review the submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented. A deficiency was found regarding two fire extinguishers in the secured dementia care unit that had not been inspected by a fire safety expert but were subsequently inspected and tagged. Ongoing compliance measures were established.
Citations (1)
Two fire extinguishers in the secured dementia care unit were not inspected by a fire safety expert as required. The fire extinguishers were later inspected, tagged, and a monthly audit plan was implemented to ensure ongoing compliance.
Report Facts
Residents Served: 97
Secured Dementia Care Unit Residents Served: 23
Current Hospice Residents: 7
Inspection Report — Jun 24, 2026
Complaint Investigation
Date: Jun 24, 2026
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection.
Complaint Details
The inspection was triggered by a complaint and incident. The submitted plan of correction was fully implemented and accepted.
Findings
The inspection found violations related to resident privacy due to unauthorized audio recording signage, incomplete medical evaluations following resident status changes, and use of incorrect standardized medical evaluation forms. The facility submitted a plan of correction which was fully implemented.
Citations (3)
42s - Privacy: A sign stating 'security camera and audio recording in use' was posted on a resident's bedroom door, violating resident privacy rights during personal care.
141b2 - Medical Evaluation Changes: A resident's status change medical evaluation was incomplete and lacked indication that the resident's needs could be safely met at the home.
251c - Standardized Forms: A resident's medical evaluation was completed on the assisted living residence form instead of the Department’s current standardized personal care home form.
Report Facts
Residents Served: 92
Secured Dementia Care Unit Residents Served: 20
Hospice Current Residents: 15
Inspection Report — May 21, 2026
Complaint Investigation
Date: May 21, 2026
Visit Reason
The inspection was conducted as a complaint and incident investigation at Oxford Crossings.
Complaint Details
The inspection was complaint-related and incident-based, investigating allegations of abuse and improper restriction of residents' rights. The abuse allegation was substantiated with corrective actions taken including staff termination and training.
Findings
The investigation found a violation involving abuse where a resident in the secured dementia unit was physically restrained and verbally abused by a staff member. Additionally, a violation was found regarding residents' rights to choose their own health care providers, with a policy change requiring residents to use in-house providers for appointment scheduling assistance.
Citations (2)
42b Abuse: A resident in the secured dementia unit was physically restrained by a staff member who held the resident's wrist and verbally abused the resident. The staff member was removed and terminated following the incident.
42y Health Care Choice: The facility sent a message requiring residents to use in-house providers for appointment scheduling assistance, which violates the resident's right to choose their own health care providers without limitation.
Report Facts
Residents Served: 86
Secured Dementia Care Unit Residents Served: 20
Hospice Current Residents: 8
Inspection Report — Mar 30, 2026
Renewal
Date: Mar 30, 2026
Visit Reason
The inspection was conducted as a renewal licensing inspection of Oxford Crossings to determine compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance overall, with a submitted plan of correction fully implemented. Several deficiencies were identified related to personal hygiene, exterior hazards, food storage, medication management, and admission support plans, all with accepted plans of correction.
Citations (8)
24 - Personal Hygiene: Resident #1 required total physical assistance with personal hygiene, but was found with uncombed and bloody hair from self-injury on 3/30/26.
100a - Exterior - Free of Hazards: Trash, empty water bottles, plastic cups, and debris were accumulated outside the emergency egress doorway of fire tower #2 on 3/30/26 at 9:30 am.
103g - Storing Food: Three tubs of ice cream in the kitchen walk-in freezer were unsealed with lids not fully closing on 3/30/26 at 10:45 am.
183d - Prescription Current: A medication prescribed for resident #2 was found in the medication cart but had been discontinued on 11/1/24, with repeat violations noted.
183e - Storing Medications: On 3/31/26, medications for resident #2 were stored with punctures in the foil backing of the blister card, contrary to manufacturer instructions.
185a - Implement Storage Procedures: Resident #2's medication administration record lacked blood sugar readings on multiple dates in March 2026.
187d - Follow Prescriber's Orders: Resident #2 received Glipizide despite blood sugar readings below the prescribed threshold on multiple occasions in March 2026.
234a - Admission Support Plan: Resident #1's initial support plan was completed more than 72 hours prior to admission to the Secure Dementia Care Unit, violating timing requirements.
Report Facts
Residents Served: 84
Secured Dementia Care Unit Residents Served: 23
Hospice Current Residents: 7
Resident with Mobility Need: 34
Resident Age 60 or Older: 84
Notice — Jan 30, 2026
Date: Jan 30, 2026
Visit Reason
The document serves to notify Oxford Crossings that their request to waive the requirement for direct care staff to have a high school diploma, GED, or active registry status has been granted due to education obtained outside the United States.
Findings
The waiver is granted under specific conditions including documentation of education equivalency and annual review during inspections to ensure compliance. Failure to comply may result in termination of the waiver or other licensing actions.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Notice — Dec 12, 2025
Date: Dec 12, 2025
Visit Reason
The document serves to notify the facility that a waiver request to 55 Pa.Code § 2600.54(a)(2) regarding direct care staff qualifications has been granted.
Findings
The waiver allows a specified employee to serve as direct care staff despite education obtained outside the United States, subject to conditions including documentation and annual review during inspections.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Notice — Dec 11, 2025
Date: Dec 11, 2025
Visit Reason
The document serves to notify the facility that a waiver request to Pennsylvania code 55 Pa.Code § 2600.54(a)(2) regarding direct care staff qualifications has been granted.
Findings
The waiver allows a specified employee to serve as direct care staff despite education obtained outside the United States, subject to conditions including documentation and annual review during inspections.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Dec 2, 2025
Follow-Up
Date: Dec 2, 2025
Visit Reason
The inspection was a follow-up visit to verify the implementation of a previously submitted plan of correction at Oxford Crossings.
Findings
The facility was found to have fully implemented the plan of correction. Deficiencies related to locking poisonous materials, sanitary conditions, medication storage, and support plan needs were addressed with corrective actions completed by the inspection date.
Citations (4)
82c Locking Poisonous Materials: Poisonous materials such as toothpaste, hand sanitizer, and nail polish remover were unlocked and accessible to residents not assessed as safe to handle them.
85a Sanitary Conditions: A resident's room had a strong odor of urine while the resident was lying on the bed, which was resolved during the inspection.
183e Storing Medications: Several blister packs of prescription tablets had punctures on the back of the packages, though the pills remained inside.
234b Support Plan Needs Elements: A resident's support plan did not address the ability to use and avoid poisonous materials, despite medication evaluation indicating inability to do so.
Report Facts
Residents Served: 84
Secured Dementia Care Unit Residents Served: 21
Current Hospice Residents: 8
Residents with Mobility Need: 31
Residents Age 60 or Older: 84
Notice — Nov 13, 2025
Date: Nov 13, 2025
Visit Reason
The document serves to notify the facility that a waiver request to Pennsylvania code 55 Pa.Code § 2600.54(a)(2) regarding direct care staff qualifications has been granted.
Findings
The waiver allows a specified employee to serve as direct care staff based on an evaluation that their foreign education is equivalent to a U.S. high school diploma. The waiver is subject to annual review during inspections and requires documentation to be maintained by the facility.
Inspection Report — Oct 27, 2025
Complaint Investigation
Date: Oct 27, 2025
Visit Reason
The inspection was a partial, unannounced complaint and incident investigation conducted over multiple days (10/27/2025, 10/29/2025, 10/30/2025) to assess compliance with regulatory requirements and investigate allegations.
Complaint Details
The inspection was complaint-related, triggered by allegations including abuse, neglect, and failure to meet resident needs. The complaint was substantiated with multiple violations found, including retaliation against a complainant.
Findings
The inspection identified multiple deficiencies including delayed access to records, failure to submit supervision plans for suspended staff, breaches in resident record confidentiality, resident abuse and neglect, inadequate staff training, medication administration errors, unsafe physical conditions, and incomplete resident documentation. Plans of correction were accepted and implemented by 01/05/2026.
Citations (31)
5a1 - DHS Access: Staff delayed providing requested internal investigation, staff, and resident records to Department agents by several hours.
15c - Supervision: Staff were suspended for alleged abuse and returned to work without an approved plan of supervision.
17 - Record Confidentiality: Resident records were left unlocked and unattended; staff recorded dementia care unit activities on personal cellphones and shared videos via WhatsApp.
42b - Abuse: A resident exited the secured dementia care unit through an unlocked window and was found unsupervised outside; exit-seeking behaviors were not addressed in the resident's support plan.
42c - Treatment of Residents: Staff referred to a resident as "creepy" during interviews, violating dignity and respect requirements.
42o - Associate/Communicate: A resident was told by staff they could not be friends with another resident, violating rights to freely associate.
42s - Privacy: Staff refused to assist a resident with showering due to inappropriate behavior and discussed resident issues with family improperly.
44b - Retaliation: Staff person A identified and yelled at an anonymous complainant, violating protections against retaliation.
65g - Annual Training Content: Staff persons G and H did not receive required emergency preparedness training during 2024.
65i - Training Record: The home's training records lacked documentation of training length for direct care staff in 2024.
81a - Accommodation: Procedures for bedside mobility devices lacked periodic assessment for proper installation and maintenance.
81b - Resident Personal Equipment: A bedside mobility device was not securely attached and had an uncovered opening exceeding FDA guidelines.
82c - Locking Poisonous Materials: Multiple poisonous materials were unlocked, unattended, and accessible to residents in the kitchenette.
85a - Sanitary Conditions: Men's common bathroom toilet was clogged with feces and a resident's room had a strong urine odor.
105g - Lint Removal and Duct Cleaning: Approximately 1-inch lint accumulation was found in the lint trap of dryers in the laundry room.
141a - Medical Evaluation Information: A resident's medical evaluation was incomplete, missing page two and documentation.
141b1 - Annual Medical Evaluation: A resident's annual medical evaluation lacked determination that the home could meet the resident's needs.
183b - Meds and Syringes Locked: Medications and syringes were found unlocked and unattended on a resident's bathroom sink; resident does not self-administer.
183d - Prescription Current: Discontinued medications remained in the home's medication cart.
187a - Medication Record: Medication administration records had discrepancies between documented administration and narcotic count sheets.
187b - Date/Time of Medication Admin.: Medication administration records lacked initials of staff administering medications at specified times.
187d - Follow Prescriber's Orders: A prescribed pain medication was not administered as ordered, with discrepancies in narcotic counts.
201 - Positive Interventions: The home failed to implement positive interventions to modify or eliminate a resident's exit-seeking behaviors.
224a - Preadmission Screen Form: Resident preadmission screening forms lacked determination that the home could meet resident needs.
224b - Assessment Referral: The home failed to refer a resident to a local assessment agency when it could not meet the resident's needs.
227d - Support Plan Medical/Dental: Resident support plans lacked documentation of medical devices, exit-seeking behaviors, hallucinations, and behavioral incidents.
227g - Support Plan Signatures: A resident participated in support plan development but did not sign the plan.
231c - Preadmission Screening: A resident admitted to the secured dementia care unit lacked a completed cognitive preadmission screening.
231e - No Objection Statement: The home lacked documentation that a resident and designated person did not object to admission to the secured dementia care unit.
235 - Discharge/Transfer/Closure: The home failed to provide a 30-day written discharge notice to a resident's designated person and imposed conditions for temporary return.
236 - Staff Training: Direct care staff in the secured dementia care unit lacked documented dementia care training hours for 2024.
Report Facts
Inspection Dates: 3
Residents Served: 84
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 8
Residents Age 60 or Older: 80
Residents with Mobility Need: 37
Staff Total Daily: 121
Staff Waking: 91
Inspection Report — Jun 2, 2025
Monitoring
Date: Jun 2, 2025
Visit Reason
The inspection was a monitoring visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing to review the facility's compliance with regulations and the implementation of a previously submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including failure to timely report incidents, incomplete criminal background checks, unqualified direct care staff, incomplete staff orientation and training, expired elevator certificates, improper medication administration, and medication storage issues. Plans of correction were accepted and implemented with ongoing monitoring and audits scheduled.
Citations (10)
Failure to report a resident's death incident to the department within 24 hours as required.
Staff person hired without an FBI background check due to not residing in Pennsylvania for over 2 years.
Direct care staff person hired without a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Administrator's staff list did not include the administrator and campus staff overseeing the building.
Ancillary staff person did not have a general orientation to specific job functions prior to working.
Direct care staff persons providing unsupervised ADL services without completing and passing the Department-approved direct care training course and competency test.
Two main elevators lacked a current certificate of operation; certificates had expired.
Staff person administered prescription medications without completing required medication administration training; paper version of training was obsolete.
Loose pills found in medication carts and a punctured resident blister pack with pill remaining inside packaging.
Staff person administered medications without completing an annual practicum required for medication administration certification.
Report Facts
Residents Served: 87
Secured Dementia Care Unit Residents Served: 15
Current Hospice Residents: 9
Total Daily Staff: 165
Waking Staff: 124
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Hired without FBI background check; removed from schedule pending fingerprinting. | |
| Staff person B | Hired without required qualifications; removed from schedule until documentation obtained; provided unsupervised ADL services without required training. | |
| Staff person C | Administrator | Maintained incomplete staff list excluding self and campus staff. |
| Staff person D | Provided unsupervised ADL services without required training; documentation secured on day of inspection. | |
| Staff person E | Administered medications without completing required medication administration training; removed from medication administration duties. | |
| Staff person F | Administered medications without completing annual practicum; removed from medication administration duties. | |
| Executive Director | Provided training and education related to multiple deficiencies and oversaw ongoing monitoring. | |
| Director of Nursing | Involved in training, audits, and medication administration oversight. | |
| Human Resource Director | Conducted employee file audits and education related to staff qualifications and orientation. | |
| Campus Director | Provided education on regulations and coordinated corrective actions. | |
| Maintenance Director | Responsible for elevator inspections and obtaining certificates. | |
| Life Enrichment Director | Educated on orientation and training guidelines for new employees. |
Inspection Report — Jan 8, 2025
Complaint Investigation
Date: Jan 8, 2025
Visit Reason
The inspection was a partial, unannounced visit conducted due to a complaint and incident involving resident care and medication administration.
Complaint Details
The inspection was triggered by a complaint and incident involving resident neglect and medication administration issues.
Findings
The inspection found multiple deficiencies including neglect related to resident care in the secured dementia care unit, staff lacking required qualifications and training, failure to follow prescriber's orders, incomplete medication administration training, and missing death certificates in resident records. Plans of correction were accepted and implemented.
Citations (7)
Neglect and mistreatment of a resident in the secured dementia care unit, including failure to seek timely medical attention and inadequate pain management.
Direct care staff person hired without a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Direct care staff person did not receive required training in medication self-administration.
Direct care staff persons did not receive annual training in fire safety, emergency preparedness, resident rights, Older Adult Protective Services Act, and falls and accident prevention.
Failure to follow prescriber's orders: medication not administered to resident due to unavailability.
Staff person administered medications without successfully completing Department-approved medication administration course.
Resident record missing official death certificate after resident passed away in hospital.
Report Facts
Residents Served: 86
Secured Dementia Care Unit Residents Served: 10
Current Hospice Residents: 2
Staff Total Daily: 118
Staff Waking: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Named in deficiencies for lacking required qualifications, missing training in medication self-administration and annual training topics, removed from schedule and terminated. | |
| Staff Person B | Named in deficiency for missing annual training topics, resigned from position. | |
| Staff Person C | Named in deficiency for missing annual training topics, required to complete training by specified date. | |
| Staff Person D | Named in deficiency for administering medications without completing required medication administration course, removed from schedule. | |
| Wellness Director | Responsible for education, audits, and monitoring compliance with medication administration and resident condition policies. | |
| Human Resources Director | Responsible for auditing employee files, onboarding processes, and training compliance reporting. |
Inspection Report — Sep 16, 2024
Complaint Investigation
Date: Sep 16, 2024
Visit Reason
The inspection was conducted as a complaint investigation following allegations received about the facility's compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Complaint Details
The inspection was complaint-driven, triggered by allegations of noncompliance with Personal Care Home regulations. The violations found led to revocation of the previous certificate of compliance and issuance of a first provisional license.
Findings
Multiple violations were found including medication errors, staff qualification deficiencies, incomplete medical evaluations, improper medication storage, and incomplete resident records. The facility was issued a first provisional license due to these violations and required to submit plans of correction.
Citations (23)
Residents 1, 2, and 3 did not receive their medications on 9/8/2024 and 9/9/2024 and the incident was not reported to the department.
Direct care staff person A lacked required qualifications such as a high school diploma, GED, or active registry status.
Direct care staff persons A and B did not complete required initial direct care training and competency testing before providing unsupervised ADL services.
Staff person C did not receive required fire safety training during the 2023 training year.
Resident 5's medical evaluation was incomplete and did not include a general physical examination or document blood pressure.
Expired or improperly stored medications found in medication carts including inhalers past discard date and loose pills.
Medications prescribed to resident 1 were not available in the home on 9/16/2024.
Medication errors involving residents 1, 2, and 3 were not reported to the resident, designated person, or prescriber.
Initial medication administration training records for staff persons B and C lacked required online user reports.
Resident 1 and 2's preadmission screening forms were incomplete or missing required information and determinations.
Resident 1's written cognitive preadmission screening and initial support plan were not completed timely.
Toilet in room A14 was backed up and overflowing; stale urine odor in room A10.
Emergency telephone numbers were not posted by telephones in rooms A31 and A37.
Residents in rooms A43, B11, and B17 lacked operable bedside lamps or lighting.
Resident 1 and 2's medical evaluations did not include special health or dietary needs.
Menus were not posted in a conspicuous and public place in the home.
Staff person A transporting residents had not completed required direct care staff training and often transported residents alone without an assistant.
Resident 3's medication storage included undated and expired inhalers, broken blister packs, and loose pills.
Resident 5's glucometer readings were missing on multiple dates despite documentation in the medication administration record.
Resident 6's preadmission screening form was not completed.
Resident 1's support plan lacked signatures from the resident and assessor.
Resident 1's support plan did not address multiple physical, medical, social, cognitive, and safety needs.
Resident 1's record did not include race, height, weight, hair and eye color, religious affiliation, identifying marks, or a recent photograph.
Report Facts
Residents Served: 89
Residents Served in Secure Dementia Care Unit: 22
Total Daily Staff: 147
Waking Staff: 110
Residents Served: 91
Total Daily Staff: 170
Waking Staff: 128
Inspection Report — Jul 29, 2024
Follow-Up
Date: Jul 29, 2024
Visit Reason
The inspection was conducted as a follow-up to verify the implementation of the plan of correction submitted for the July 29 and 30, 2024 inspection, with additional reasons including renewal, complaint, and monitoring.
Findings
The inspection identified multiple deficiencies including failure to post current license documents, failure to report incidents timely, inadequate supervision of residents during transport, incomplete staff training, improper medication storage and administration, incomplete resident support plans, and safety concerns such as unsecured mobility devices and missing emergency phone numbers. Plans of correction were submitted with various completion dates, some of which were not fully implemented as of the follow-up.
Citations (23)
The home's current violation report and a copy of 55 Pa.Code Chapter 2600 were not posted in a conspicuous and public place.
Failure to report an incident involving resident left unattended and unsupervised to the Department within 24 hours.
Resident 1 was left unattended and unsupervised during transport without required escort.
Direct care staff person A did not complete required annual training hours and specific training topics in 2023.
Bedside mobility devices were not securely attached to residents' bedframes.
Poisonous materials were unlocked and accessible to residents not assessed as safe to use them.
Strong odor and unsanitary conditions in resident room C16.
Emergency telephone numbers were not posted in resident rooms A09 and B25.
Residents 1 and 6 did not have access to operable lamps or lighting at bedside.
Annual fire safety inspection was overdue; last conducted on 6/26/2023.
Resident 7's medical evaluation was not completed within required timeframe relative to admission.
Staff person B transported residents without completing required annual direct care staff training.
Resident 1 transported without required assistant escort; resident unbuckled seatbelt and walked in moving vehicle.
Medication storage deficiencies including torn bubble packs and expired/opened medications not discarded.
Blood sugar readings were inaccurately recorded or missing in residents' medication administration records.
Medication administration documentation was incomplete or untimely, including failure to initial or sign narcotics log.
Medications were not administered according to prescriber's sliding scale orders and timing requirements.
Staff person A administered insulin without completing required diabetes education within past 12 months.
Resident 10's additional assessments were not completed timely.
Resident support plans did not document specific needs, intended use, risks, or safe use of bedside mobility devices.
Support plans lacked signatures from residents and assessors.
Directions for operating key-locking devices at Secure Dementia Care Unit were not conspicuously posted.
Direct care staff person A lacked required additional 6 hours of dementia care training for 2023.
Report Facts
Residents Served: 84
Secured Dementia Care Unit Residents Served: 22
Hospice Residents: 6
Staffing Hours - Total Daily Staff: 142
Staffing Hours - Waking Staff: 107
Deficiencies Cited: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Direct Care Staff Person | Named in findings related to incomplete annual training, lack of dementia care training, and insulin administration without required education. |
| Staff Person B | Transportation Staff | Named in findings related to transporting residents without completing required annual training. |
| Staff Person C | Staff Person | Named in findings related to medication administration errors including failure to initial and sign narcotics log. |
| Executive Director | Mentioned in relation to oversight and communication with third party contractors and regulatory authorities. | |
| Wellness Director | Mentioned extensively in relation to monitoring, training, audits, and corrective actions. | |
| Transportation Coordinator | Mentioned in relation to transportation oversight, training, and auditing transport requests. | |
| Director of Maintenance | Mentioned in relation to securing equipment and conducting audits. | |
| Human Resource Director | Mentioned in relation to monitoring staff training compliance. |
Inspection Report — Nov 30, 2023
Complaint Investigation
Date: Nov 30, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection on 11/30/2023.
Complaint Details
The visit was complaint-related, triggered by a complaint and incident. The plan of correction was accepted on 01/09/2024 and fully implemented by 02/07/2024.
Findings
The inspection found violations related to the treatment of residents with dignity and respect, including inappropriate staff behavior captured on video, and failure to have criminal background checks on private caregivers working in the home. Plans of correction were submitted and fully implemented by 02/07/2024.
Citations (2)
Resident was treated disrespectfully by staff, including harsh language and refusal to assist appropriately, as captured on hidden camera.
Failure to have a criminal background check on file for a private caregiver employed by a resident.
Report Facts
Residents Served: 69
Memory Care Residents Served: 17
Hospice Residents: 6
Residents with Mobility Need: 31
Residents with Physical Disability: 2
Residents Diagnosed with Intellectual Disability: 1
Total Daily Staff: 100
Waking Staff: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Simmers | Administrator | Named as facility administrator |
Inspection Report — Jun 6, 2023
Follow-Up
Date: Jun 6, 2023
Visit Reason
This follow-up inspection was conducted to review the submitted plan of correction for previously identified deficiencies from the June 6 and 7, 2023 inspection at Oxford Crossings.
Findings
The inspection found multiple deficiencies related to incident reporting, criminal background checks, staff training, medication administration, sanitary conditions, fire safety, resident records, and other regulatory requirements. The facility submitted plans of correction which were accepted and implemented by August 9, 2023.
Citations (24)
Failure to report incidents to the Department within 24 hours and submit final incident reports.
Failure to issue timely refunds to residents' estates after death.
Employees working without criminal background checks.
Staff training plan lacked required details including names, positions, and training schedules.
Poisonous materials were accessible to residents without proper locking.
Failure to maintain sanitary conditions including hand hygiene and uncovered trash receptacles.
Damaged carpet presenting a hazard.
Clogged bathroom sinks in resident rooms.
Undated and outdated emergency food items stored improperly.
Lack of documentation for annual emergency management agency submission.
Missing documentation of last fire safety inspection and drill by a fire safety expert.
No maximum safe evacuation time specified in writing by a fire safety expert; multiple fire drills exceeded 2 minutes 30 seconds.
Fire drills routinely held on Saturdays, not varied days/times.
Menus not posted in a conspicuous place in the memory care unit.
Staff administered medications without current certification; medication errors including failure to administer and improper documentation.
Medications and syringes not kept locked and accessible to residents.
Discontinued medications not removed and destroyed properly.
Medications prescribed to residents were not available in the home.
Medication records incomplete; missing prescribed medications on MAR.
Failure to follow prescriber's orders; medications destroyed without administration.
Medication errors not reported to resident, designated person, or prescriber.
Medication error documentation missing in resident record.
Resident support plans missing documentation of medical needs such as low-cholesterol diet.
Resident records incomplete; missing hair color, eye color, height, race, religion, or photo.
Report Facts
Residents served: 12
Staffing: 68
Staffing: 91
Inspection dates: Inspection conducted on June 6 and 7, 2023
Plan of correction submission dates: Plans accepted July 13, 2023 and implemented by August 9, 2023
Inspection Report — Jan 30, 2023
Date: Jan 30, 2023
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Residents Served: 61
Secured Dementia Care Unit Residents Served: 12
Hospice Current Residents: 4
Inspection Report — Aug 25, 2022
Date: Aug 25, 2022
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 66
Residents Served in Dementia Care Unit: 13
Total Daily Staff: 89
Waking Staff: 67
Residents with Mobility Need: 23
Residents 60 Years or Older: 66
Inspection Report — Jun 3, 2022
Routine
Date: Jun 3, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 06/03/2022.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 73
Secured Dementia Care Unit Residents Served: 19
Hospice Residents: 9
Resident Mobility Need: 28
Total Daily Staff: 101
Waking Staff: 76
Inspection Report — May 17, 2022
Complaint Investigation
Date: May 17, 2022
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 05/17/2022 and 05/23/2022 to review compliance with submitted plans of correction.
Complaint Details
The inspection was complaint-driven, with a follow-up to verify the submitted plan of correction was fully implemented. The plan of correction was accepted and compliance was confirmed.
Findings
The facility was found to have deficiencies related to medication administration and documentation, specifically failure to administer prescribed medications to Resident 1 as ordered. Staff education and corrective actions were implemented and verified by follow-up document submissions.
Citations (2)
Failure to implement safe storage, access, security, distribution, and use of medications and medical equipment by trained staff, resulting in Resident 1 not receiving prescribed medication at bedtime.
Failure to follow prescriber's orders, Resident 1 was not administered prescribed medication as ordered.
Report Facts
Residents Served: 73
Secured Dementia Care Unit Residents Served: 19
Hospice Current Residents: 9
Total Daily Staff: 73
Waking Staff: 55
Inspection Report — Feb 11, 2022
Original Licensing
Date: Feb 11, 2022
Visit Reason
The inspection was conducted as a licensing inspection for a new legal entity operating the personal care home, Oxford Crossings, to assess compliance with 55 Pa. Code Chapter 2600 regulations.
Findings
The facility was found to be in substantial compliance with applicable regulations at the time of inspection. The licensing inspector was unable to complete a full inspection due to the new legal entity status, and a re-inspection will be conducted within three months.
Report Facts
Residents served: 75
Residents served in Secure Dementia Care Unit: 16
Hospice current residents: 7
Resident support staff: 0
Total daily staff: 100
Waking staff: 75
Residents aged 60 or older: 75
Residents diagnosed with mental illness: 23
Residents diagnosed with intellectual disability: 1
Residents with mobility need: 25
Residents with physical disability: 0
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