Inspection Reports for Oxford Crossings
310 E Winchester Ave, Langhorne, PA 19047, United States, PA, 19047
Back to Facility ProfileDeficiencies per Year
24
18
12
6
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Monitoring
Census: 87
Capacity: 116
Deficiencies: 10
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.
Deficiencies (10)
| Description |
|---|
| 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
License Capacity: 116
Residents Served: 87
Secured Dementia Care Unit Capacity: 27
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
Complaint Investigation
Census: 86
Capacity: 116
Deficiencies: 7
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.
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.
Complaint Details
The inspection was triggered by a complaint and incident involving resident neglect and medication administration issues.
Deficiencies (7)
| Description |
|---|
| 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
License Capacity: 116
Residents Served: 86
Secured Dementia Care Unit Capacity: 17
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
Complaint Investigation
Census: 89
Capacity: 116
Deficiencies: 12
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.
Findings
Multiple violations were found including medication errors, staff qualifications, training 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.
Complaint Details
The inspection was complaint-driven based on allegations received. The violations found were substantiated and resulted in revocation of the previous certificate of compliance and issuance of a first provisional license.
Deficiencies (12)
| Description |
|---|
| 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 does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| 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 completed by a fire safety expert during the 2023 training year. |
| Resident 5's medical evaluation did not include a complete general physical examination; blood pressure was not documented. |
| Resident 6's Breo Ellipta inhaler and resident 7's Anoro Ellipta inhaler were expired and improperly stored in medication cart. |
| Resident 1's prescribed medications (Acetaminophen and Nicotine patches) 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 did not include required online user reports. |
| Resident 1’s and Resident 2’s preadmission screening forms did not include determinations that needs could be met by the home and were incomplete. |
| Resident 1’s written cognitive preadmission screening was completed late, not within 72 hours prior to admission to secured dementia care unit. |
| Resident 1’s initial support plan was completed late, not within 72 hours of admission to secured dementia care unit. |
Report Facts
License Capacity: 116
Residents Served: 89
Secure Dementia Care Unit Capacity: 27
Residents Served in Secure Dementia Care Unit: 22
Total Daily Staff: 147
Waking Staff: 110
Number of Deficiencies: 12
Inspection Report
Complaint Investigation
Census: 89
Capacity: 116
Deficiencies: 23
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.
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.
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.
Deficiencies (23)
| Description |
|---|
| 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
License Capacity: 116
Residents Served: 89
Secure Dementia Care Unit Capacity: 27
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
Follow-Up
Census: 84
Capacity: 116
Deficiencies: 23
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.
Deficiencies (23)
| Description |
|---|
| 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
License Capacity: 116
Residents Served: 84
Secured Dementia Care Unit Capacity: 27
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
Complaint Investigation
Census: 69
Capacity: 116
Deficiencies: 2
Nov 30, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection on 11/30/2023.
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.
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.
Deficiencies (2)
| Description |
|---|
| 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
License Capacity: 116
Residents Served: 69
Memory Care Unit Capacity: 27
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
Follow-Up
Census: 12
Capacity: 27
Deficiencies: 24
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.
Deficiencies (24)
| Description |
|---|
| 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
Total capacity: 27
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
Census: 61
Capacity: 116
Deficiencies: 0
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
License Capacity: 116
Secured Dementia Care Unit Capacity: 27
Secured Dementia Care Unit Residents Served: 12
Hospice Current Residents: 4
Inspection Report
Census: 66
Capacity: 116
Deficiencies: 0
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
License Capacity: 116
Residents Served: 66
Secured Dementia Care Unit Capacity: 27
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
Routine
Census: 73
Capacity: 116
Deficiencies: 0
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
License Capacity: 116
Residents Served: 73
Secured Dementia Care Unit Capacity: 27
Secured Dementia Care Unit Residents Served: 19
Hospice Residents: 9
Resident Mobility Need: 28
Total Daily Staff: 101
Waking Staff: 76
Inspection Report
Complaint Investigation
Census: 73
Capacity: 116
Deficiencies: 2
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.
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.
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.
Deficiencies (2)
| Description |
|---|
| 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
License Capacity: 116
Residents Served: 73
Secured Dementia Care Unit Capacity: 27
Secured Dementia Care Unit Residents Served: 19
Hospice Current Residents: 9
Total Daily Staff: 73
Waking Staff: 55
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