Oxford Rehab: Repeated Quality of Care Violations - PA]
Oxford Rehabilitation and Healthcare Center, a 300-bed skilled nursing facility on East Winchester Avenue, received a deficiency under the federal quality of care standard after inspectors determined that some residents were not receiving care that met professional standards. The violation was first cited at the facility on November 15, 2024. Inspectors returned and found it again, essentially unchanged, exactly one year later.
The repeat citation is significant not because any single finding in this report describes catastrophic harm, but because of what it says about whether anything changed in between. The federal classification assigned to the deficiency was "minimal harm or potential for actual harm," the lowest tier of severity. But a violation cited twice, in consecutive annual inspections, at the same facility, affecting multiple residents both times, is a facility that has not fixed a known problem.
Federal inspection reports at this level of detail do not always name individual residents or describe specific incidents in full. This one does not. What it records is the regulatory conclusion: some residents were affected, the standard of care was not met, and the nursing staff practices that govern how that care is delivered fell short of what Pennsylvania and federal rules require.
The citation references two Pennsylvania state nursing home codes alongside the federal standard. One governs resident care policies. The other governs nursing services, specifically the obligations of nursing staff to assess residents, identify their needs, and respond. Both were cited together in 2024. Both appear again in 2025.
Oxford Rehabilitation and Healthcare Center has not publicly commented on the findings. Facilities cited under the federal inspection process are required to submit a plan of correction to the state survey agency, but those plans are not always made public in the inspection report itself. This report notes only that anyone seeking information on Oxford's correction plan should contact the facility or the Pennsylvania Department of Health directly.
What the report does not contain is also worth noting. There is no immediate jeopardy designation, which would indicate that inspectors believed residents faced a risk of serious injury or death. There is no finding of actual harm at a higher severity level. The residents described as affected are not named, and their specific conditions or outcomes are not detailed in the portion of the report available for review.
None of that makes the repeat citation routine.
Nursing home inspections operate on a logic of correction: a facility is cited, it submits a plan, it implements changes, and the next inspection confirms the problem is resolved. When inspectors return a year later and cite the same deficiency, that logic has broken down somewhere. Either the plan of correction was inadequate, or it was adequate on paper and not followed in practice, or the underlying staffing or policy conditions that produced the first violation were never actually addressed.
The Pennsylvania Department of Health, which conducts inspections on behalf of the federal Centers for Medicare and Medicaid Services, completed this inspection on November 14, 2025. The report was printed April 13, 2026.
Oxford Rehabilitation and Healthcare Center's federal facility identification number is 395710. Its inspection history, including the 2024 citation this finding repeats, is publicly available through the CMS Care Compare database.
For the residents living at Oxford during the period covered by this inspection, the classification of "minimal harm or potential for actual harm" is a regulatory designation, not a guarantee of what they experienced. It means inspectors did not find evidence of serious injury tied to this deficiency. It does not mean the care they received met the standard it was supposed to meet. The report says it did not.
A year passed between the first citation and the second. The problem, according to federal inspectors, was still there.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oxford Rehabilitation and Healthcare Center from 2025-11-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 1, 2026 · Our methodology
OXFORD REHABILITATION AND HEALTHCARE CENTER in LANGHORNE, PA was cited for violations during a health inspection on November 14, 2025.
The violation was first cited at the facility on November 15, 2024.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.