Inspection Reports for
Oakbridge Terrace at Southampton Estates
238 STREET ROAD, SOUTHAMPTON, PA, 18966
Back to Facility Profile18 Reports
Inspection Report — Oct 20, 2025
Renewal
Date: Oct 20, 2025
Visit Reason
The inspection was conducted as a renewal visit to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to have fully implemented the submitted plan of correction. Two fire safety deficiencies were identified related to evacuation time exceeding the specified limit and fire drills being routinely held on the same week of the month. Corrective actions and monitoring plans were implemented and accepted.
Citations (2)
132d Evacuation: The facility exceeded the maximum safe evacuation time of 13 minutes during a fire drill on 7/16/2025, with an evacuation time of 13 minutes and 36 seconds.
132g Fire drills – days/times: The facility routinely held fire drills during the last week of the month on multiple occasions, not varying days and times as required.
Report Facts
Residents Served: 43
Special Care Unit Residents Served: 21
Hospice Residents: 1
Evacuation Time Limit: 780
Evacuation Time Recorded: 816
Inspection Report — Aug 16, 2023
Renewal
Date: Aug 16, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The facility was found to have multiple deficiencies including incomplete resident-residence contracts, failure to use alternate exit routes during fire drills, missing posted menus, presence of discontinued medications, incomplete core service packages, and insufficient dementia care training for staff. All deficiencies had plans of correction accepted and were reported as implemented by 10/11/2023.
Citations (6)
Resident-residence contracts did not identify the assisted living services included in the core service package and the total price for those services.
The home did not indicate the exit used as an alternate exit route during fire drills held from January 2023 to July 2023.
Weekly menus were not posted in a conspicuous and public place in the residence.
Discontinued medication Ketorolac Tromethamine was found in the medication cart despite being discontinued on 05/12/23.
The residence was not providing the required Independent Core Package and Enhanced Core Package services.
Staff persons A, B, and C working in the special care unit had only completed 4 hours of initial dementia care training within the first 30 days of hire instead of the required 8 hours.
Report Facts
Residents Served: 33
Special Care Unit Residents Served: 14
Total Daily Staff: 47
Waking Staff: 35
Discontinued Medication Date: May 12, 2023
Plan of Correction Completion Date: Oct 7, 2023
Inspection Report — May 18, 2022
Renewal
Date: May 18, 2022
Visit Reason
The inspection was conducted as a renewal visit to review the facility's compliance with licensing requirements.
Findings
The inspection identified several deficiencies related to kitchen and food storage practices, emergency procedure submissions, and key-locking device signage. All deficiencies had accepted plans of correction that were implemented or scheduled for follow-up audits.
Citations (5)
Five uncovered trash cans were found in the kitchen.
An opened and unsealed bag of long grain rice was found in the dry storage area.
Unlabeled and undated food items including whole grain egg noodles, flour tortillas, long grain rice, and marshmallows were found in dry storage.
The residence's written emergency procedures were submitted late; previous submission was over a year prior.
Directions for operating the residence's locking mechanism were not conspicuously posted near the garden exit in the special care unit.
Report Facts
Residents Served: 23
Special Care Unit Residents Served: 8
Current Hospice Residents: 1
Total Daily Staff: 31
Waking Staff: 23
Residents Diagnosed with Mental Illness: 4
Residents with Mobility Need: 8
Residents 60 Years or Older: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Parker | Signed the letter confirming plan of correction implementation. | |
| Director of Culinary | Responsible for weekly audits related to kitchen deficiencies. | |
| Administrator | Responsible for auditing signage presence at egress doors in special care unit. |
Inspection Report — Jan 21, 2022
Follow-Up
Date: Jan 21, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the plan of correction related to sanitary conditions involving the improper sharing of a resident's glucometer. Continued compliance must be maintained.
Citations (1)
On 01/09/2022, staff used resident #1's glucometer to check the blood sugar level of resident #2, violating sanitary conditions.
Report Facts
Residents Served: 31
Total Daily Staff: 33
Waking Staff: 25
Residents 60 Years or Older: 30
Residents Diagnosed with Mental Illness: 9
Residents with Mobility Need: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Claire Mendez | Signed letter confirming plan of correction implementation |
Notice — Jul 7, 2021
Date: Jul 7, 2021
Visit Reason
The document serves as a renewal notification and license issuance for Oakbridge Terrace at Southampton Estates, an assisted living home, following receipt of the renewal application dated June 15, 2021.
Findings
The Department issued a regular license in response to the renewal application and advised that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report — May 18, 2021
Renewal
Date: May 18, 2021
Visit Reason
The inspection was conducted as a renewal licensing inspection of the facility.
Findings
No regulatory citations or deficiencies were identified during this licensing inspection.
Report Facts
Residents Served: 15
Special Care Unit Residents Served: 0
Inspection Report — May 21, 2020
Routine
Date: May 21, 2020
Visit Reason
The Department’s Bureau of Human Services Licensing Representatives conducted an inspection of the assisted living facility to assess compliance with 55 Pa. Code Ch. 2800.
Findings
No regulatory citations were identified as a result of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mia Johnson | Human Services Licensing Supervisor | Signed as the licensing supervisor conducting the inspection. |
Notice — Feb 5, 2020
Date: Feb 5, 2020
Visit Reason
This document serves as a renewal notice and certificate of compliance for Oakbridge Terrace at Southampton Estates, confirming the facility's license to operate an Assisted Living-Special Care home. It also informs the recipient of the requirement for an annual onsite inspection within the next twelve months.
Findings
The document does not report inspection findings but confirms issuance of a regular license following the renewal application and states that the Department will conduct an annual inspection within twelve months.
Report Facts
Inspection Report — Nov 14, 2019
Renewal
Date: Nov 14, 2019
Visit Reason
The inspection was an unannounced full inspection conducted for the purpose of license renewal.
Findings
The submitted plan of correction from a prior inspection was found to be fully implemented. Deficiencies involved issues such as unsigned resident contracts, lack of signed acknowledgments of resident rights, tripping hazards from oxygen tubing, unsecured medications, incomplete preliminary support plans, and missing documentation of admission agreements to special care units.
Citations (7)
Resident #1's contract dated 5/21/19 was not signed by the resident, and the resident refused to sign it. The contract was signed by the Power of Attorney, and documentation of refusal was missing.
Resident #1's record lacked a signed statement acknowledging receipt of resident rights and complaint procedures. The contract was signed by the Power of Attorney but missing resident signature.
Oxygen tubing stretched across the hallway in bedroom 202 created a tripping hazard. Staff were present to mitigate the hazard, but Resident #2 refused to switch to a portable oxygen tank.
Resident #3 self-administered medications and stored them unlocked and unattended in the apartment. Education was provided on securing medications and locking doors.
Resident #1 was not educated on the right to refuse medication despite potential medication errors. The contract was unsigned by the resident but signed by the Power of Attorney.
Resident #4's preliminary support plan was not completed until after admission. The signature page was missing at the time of survey but later located on the chart.
Resident #1's admission to the special care unit lacked documentation of agreement by the resident or family. The contract was unsigned by the resident but signed by the Power of Attorney.
Report Facts
Residents Served: 32
Special Care Unit Residents Served: 14
Residents with Mobility Need: 14
Residents 60 Years or Older: 32
Inspection Report — Feb 6, 2019
Renewal
Date: Feb 6, 2019
Visit Reason
This document is a renewal license issued in response to a renewal application for Oakbridge Terrace at Southampton Estates, an Assisted Living Home. The Department advises that an annual onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It serves as a certificate of compliance and license renewal notification.
Report Facts
Inspection Report — Dec 13, 2018
Renewal
Date: Dec 13, 2018
Visit Reason
The inspection was a full renewal inspection conducted on December 13, 2018, for Oakbridge Terrace at Southampton Estates as part of the Department of Human Services Bureau of Human Services Licensing annual inspection process.
Findings
The inspection found violations including exceeding the secured dementia care unit capacity, use of the same fire exit routes for 11 consecutive months, presence of expired medication on the medication cart, and incomplete annual assessments by unqualified staff. Plans of correction were initiated and partially implemented as of February 12, 2019.
Citations (4)
Regulation 2800.13(b): The home exceeded the licensed secured dementia care unit capacity by having 15 residents on 12-13-18, while the licensed capacity is 14.
Regulation 2800.132(f): The home used the same fire exit routes (Service Hall / Garden) for 11 consecutive months from April 2017 to February 2018.
Regulation 2800.183(f): An expired Latanoprost Ophthalmic solution with a discard date of 11/26/2018 was found on the medication cart for resident #2 on 12/13/2018.
Regulation 2800.225(a): Resident #1 had her annual assessment completed on 03/17/2017 by staff A, who was neither the administrator nor an RN/LPN.
Report Facts
Number of Residents Served: 30
Residents in Secured Dementia Care Unit: 15
Number of Residents 60 Years or Older: 30
Number of Residents with Mobility Need: 14
Number of Residents with Physical Disability: 1
Notice — Feb 21, 2018
Date: Feb 21, 2018
Visit Reason
This document serves as a renewal notification and license issuance for Oakbridge Terrace at Southampton Estates, an assisted living home, confirming the facility's compliance and informing about the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application and outlines the Department's plan to conduct an annual inspection within twelve months.
Report Facts
Notice — Jun 7, 2017
Date: Jun 7, 2017
Visit Reason
The document serves as a waiver approval for 55 Pa.Code § 2800.64(a) relating to administrator training and orientation at the licensed assisted living residence Oakbridge Terrace at Southampton Estates.
Findings
The waiver is granted with specific conditions including attendance at an orientation session and documentation requirements. The waiver is effective from May 22, 2017 to July 10, 2017, after which full compliance is expected.
Inspection Report — Mar 30, 2017
Renewal
Date: Mar 30, 2017
Visit Reason
The inspection was a full renewal licensing inspection of Oakbridge Terrace at Southampton Estates conducted by the Pennsylvania Department of Human Services on March 30, 2017.
Findings
Violations related to 55 Pa.Code Ch. 2800 (Assisted Living Residences) were found and specified in the enclosed License Inspection Summary. A plan of correction was submitted addressing a deficiency in resident medical evaluation and health care.
Citations (1)
Regulation § 2800.141(b)(1): Resident #1 did not have a completed annual medical evaluation as required. The last medical evaluation was completed on 2/28/17, after admission in 2016.
Report Facts
Number of Residents Served: 34
Number of Residents Served in Secured Dementia Care Unit: 14
Number of Current Hospice Residents: 0
Number of Hospice Residents in Past Year: 1
Number of Residents 60 Years or Older: 34
Number of Residents with Mobility Need: 15
Number of Residents with Physical Disability: 1
Inspection Report — Feb 17, 2017
Renewal
Date: Feb 17, 2017
Visit Reason
The document is a renewal of the license to operate Oakbridge Terrace at Southampton Estates as an Assisted Living-Special Care facility. The Department of Human Services will conduct an onsite inspection within the next twelve months as part of the annual inspection requirement.
Findings
No inspection findings are detailed in this document. It primarily serves as a license renewal certificate and notification letter regarding upcoming inspections.
Report Facts
Inspection Report — Mar 23, 2016
Renewal
Date: Mar 23, 2016
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing renewal inspections on March 23 and 24, 2016 for Oakbridge Terrace at Southampton Estates.
Findings
Violations of 55 Pa.Code Ch. 2800 related to Assisted Living Residences were found, including issues with fire drill alarms and medication storage. Plans of correction were submitted and partially implemented to address these deficiencies.
Citations (2)
132i - A fire alarm or smoke detector shall be set off during each fire drill. The facility's fire drill record documented a silent alarm on 6/8/15, and staff confirmed no audible alarm was activated during the drill.
183d - Only current prescription, OTC medications, sample and CAM for individuals living in the residence may be kept in the residence. A vial of Lantus insulin expired on 3/20/16 was found in the medication cart belonging to Resident #1.
Report Facts
Number of Residents Served: 33
Number of Residents Served in Secured Dementia Care Unit: 13
Number of Current Hospice Residents: 0
Number of Hospice Residents in past year: 1
Number of Residents Age 60 or Older: 33
Number of Residents with Mobility Need: 14
Number of Residents with Physical Disability: 1
Notice — Feb 19, 2016
Date: Feb 19, 2016
Visit Reason
The document serves as a renewal notification and license issuance for the assisted living home Oakbridge Terrace at Southampton Estates, confirming the facility's authorized capacity and informing about the requirement for annual inspections.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application and outlines the Department's obligation to conduct annual inspections.
Report Facts
Report — November 15, 2024
November 15, 2024
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