Oxford Crossings.

“Resident requiring total physical assistance with personal hygiene had uncombed hair and bloody scalp from self-injury, indicating failure to provide adequate personal hygiene assistance as required by the assessment and support plan.”

“Exterior building grounds had collection of trash, empty water bottles, plastic cups, and other debris accumulated outside of the emergency egress doorway of fire tower #2, creating a hazard.”

“Three tubs of ice cream in the walk-in freezer were unsealed with lids not fully closing properly, violating the requirement that food be stored in closed or sealed containers.”

“Multiple residents did not receive prescribed treatments and medications at correct times: Resident #2 missed a blood glucose check between 2/6-2/11/26 with scheduled 2/10/26 reading taken on 2/11/26; Resident #3's blood glucose check scheduled for specific days/times was not performed as ordered; Resident #4's prescribed lumbosacral wound cleansing on 3/30/26 was not performed until approximately 12:00 pm instead of 9:00 am. This is a repeated violation.”

“Resident #1 was admitted to the Secure Dementia Care Unit in 2025, but the initial support plan was completed on 8/31/25, which was more than 72 hours prior to admission, failing to meet the requirement for timely support plan development.”

“Poisonous materials including toothpaste, hand sanitizer gel, and nail polish remover were unlocked, unattended, and accessible to residents. Not all residents had been assessed as capable of safely recognizing and using poisons.”

“A room in the memory care unit had a strong odor of urine with a resident inside lying on the bed at 9:30 am, indicating unsanitary conditions.”

“Multiple blister packs of prescribed medications had punctures on the back of the packages with pills remaining inside, indicating improper storage and handling of medications not in accordance with manufacturer's instructions.”

“A resident's support plan did not address the ability to use and avoid poisonous materials, despite medication evaluation documentation indicating the resident cannot safely use or avoid poisonous materials.”

“Staff person A failed to provide immediate access to requested documents (internal investigation file, assignment sheets, staff records, and resident files) to a Department agent. Documents were provided between 1-4 hours after requests were made at 9:27 am, 10:45 am, and 11:33 am.”

“Staff persons B, C, D, and E were suspended due to resident allegations of abuse but were returned to work without an approved plan of supervision submitted to the Department's personal care home regional office.”

“The Director of Wellness's office door was propped open with resident records unlocked, unattended, and accessible to unauthorized personnel. Additionally, activity staff were recording videos of residents in the secured dementia care unit on personal cellphones and sharing them via WhatsApp with other staff.”

“A resident in the secured dementia care unit exited through an unlocked bedroom window and wandered unsupervised in the parking lot and surrounding streets for 10-15 minutes. Staff person D had shown the resident the window, and the resident's assessment and support plan did not document exit-seeking behaviors or a supervision plan despite the resident being documented as high-functioning and requiring extensive supervision.”

“During staff interviews, a resident was referred to as 'creepy,' violating the requirement that residents be treated with dignity and respect.”

“A resident was told by an unknown staff person that they could not be friends with another resident, restricting the resident's right to freely associate and communicate with others.”

“A staff person refused to assist a resident with showering and told the resident's family member to be careful with the resident, violating the resident's right to privacy and assistance during bathing.”

“The facility failed to report a resident's death to the Department within 24 hours as required. The resident passed away at the hospital after being sent to the emergency room, but the facility did not report this incident to the department within the required timeframe.”

“A staff person was hired and had not resided in Pennsylvania for over 2 years, yet an FBI background check was not completed as required for this individual.”

“Direct care staff person B was hired but does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry as required for direct care staff.”

“The administrator maintained a list of staff persons that did not include the administrator and campus staff that work in and oversee the building.”

“Ancillary staff person A did not have a general orientation to specific job functions prior to working in that capacity.”

“Direct care staff person B began providing unsupervised ADL services without completing and passing the Department-approved direct care training course and competency test. Direct care staff person D also began providing unsupervised ADL services without completing and passing the Department-approved direct care training course and competency test.”

“Direct care staff person hired did not receive required medication self-administration training during the training year.”

“A resident with a serious antibiotic-resistant infection was not monitored adequately over multiple days despite showing signs of illness (weakness, stomach pain, decreased appetite, pain complaints). The resident was eventually transported to the hospital via EMS and died from sepsis and the infection. The home failed to seek medical attention from the time symptoms were first observed until hospital admission.”

“Direct care staff person hired does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry, which are required qualifications for direct care staff.”

“Three direct care staff persons did not receive required annual training in fire safety, emergency preparedness procedures, resident rights, the Older Adult Protective Services Act, and falls and accident prevention during the training year January 1, 2024 to December 31, 2024.”

“A resident prescribed a medication once daily did not receive the medication over a period of time because the medication was not available in the home, resulting in the failure to follow the prescriber's orders.”

“On September 8, 2024 at 8 AM and September 9, 2024 at 9 PM, residents 1, 2, and 3 did not receive their medications. The home did not report this incident to the Department within 24 hours as required.”

“Direct care staff person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry, in violation of direct care staff qualifications requirements.”

“Direct care staff person A and staff person B began providing unsupervised ADL services without completing and passing the Department-approved direct care training course, competency test, or the required initial direct care training including safe management techniques, ADLs, personal hygiene, dementia care, gerontology, and other required topics.”

“Staff person C did not receive training in fire safety completed by a fire safety expert or by a staff person trained by a fire safety expert, as required for annual training.”

“Staff person C did not receive training in fire safety completed by a fire safety expert or by a staff person trained by a fire safety expert, as required for annual training.”

“On September 8, 2024 at 8 AM and September 9, 2024 at 9 PM, residents 1, 2, and 3 did not receive their medications. The home did not report this incident to the Department within 24 hours as required.”

“Direct care staff person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry, in violation of direct care staff qualifications requirements.”

“Direct care staff person A and staff person B began providing unsupervised ADL services without completing and passing the Department-approved direct care training course, competency test, or the required initial direct care training including safe management techniques, ADLs, personal hygiene, dementia care, gerontology, and other required topics.”

“The home's current violation report and a copy of 55 Pa.Code Chapter 2600 were not posted in a conspicuous and public place in the home.”

“On 5/21/2024, a resident in the Secured Dementia Care Unit who requires regular supervision and cannot leave the home unattended was left unattended and unsupervised. The home was made aware of this incident the same day but did not submit an incident report to the Department within 24 hours as required.”

“A resident in the Secured Dementia Care Unit with an assessment and support plan indicating the resident cannot leave the home unattended and must have an escort when leaving the secured unit did not receive this assistance on 5/21/2024. The resident was left unattended and unsupervised during transportation.”

“A resident with dementia in the Secured Dementia Care Unit who requires regular supervision and cannot leave the home unattended was transported to a facility on 5/21/2024 by transportation staff, dropped off in the waiting room without alerting facility staff, and left unattended and unsupervised for an undetermined period of time, constituting neglect.”

“Staff member treated residents with disrespect and lack of dignity. Video recordings documented staff member speaking harshly to residents, refusing assistance, using insulting language, and making demeaning comments during care provision. Staff member was ultimately terminated following investigation.”

“A private caregiver employed by a resident has been working in the facility since the resident's admission without a required criminal background check on file. This was a repeated violation from prior inspections. The facility was unaware of the caregiver's presence.”

“A staff person failed to wash hands prior to administering medication to resident 16 at 12:45 p.m. on June 7, 2023, violating sanitary conditions and hand hygiene requirements.”

“The facility's staff training plan does not include required elements: the name, position, and duties of each direct care staff person, required training courses, and the dates, times, and locations of scheduled training for the upcoming year.”

“Refunds for deceased residents' personal property were not issued within 30 days as required. Residents 5-13 passed away and their personal belongings were removed from their rooms, but refund checks were delayed or not properly documented in resident records.”

“Two employees from Sherwin-Williams began work on the second floor near residents without providing criminal background checks prior to starting the job. Background checks are required before individuals can work on the premises.”

“The facility failed to report an incident involving medication administration errors for residents 1 and 2 to the Department until August 1, 2022. Reportable incidents must be reported to the Department within 24 hours.”