Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oxford Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Two residents did not receive care according to physician orders: one was given blood pressure medication without required pre-administration BP checks and did not receive as-needed antihypertensive medication when indicated, while another did not have a prescribed compression stocking applied to a swollen leg as ordered. The DON confirmed these lapses in care.
The facility did not maintain a medication error rate below 5%, with two errors observed out of 28 medication administration opportunities. One resident received only half the prescribed dose of Losartan for cardiac conditions, and another received a crushed Protonix delayed release tablet, contrary to administration instructions. The DON confirmed these errors.
A resident was found in a room with small flying insects around her head, ants on the mattress and dresser, large cobwebs by the window, a dried yellow substance on the floor, and a dresser drawer that did not close properly. A family member confirmed ongoing issues with insects, the persistent yellow stain, and the malfunctioning drawer.
The facility failed to maintain accurate and complete medical records for two residents, both diagnosed with muscle wasting and anemia. Despite residents confirming that treatments were administered as ordered, the treatment administration records lacked documentation for specific dates. The Director of Nursing confirmed the documentation failure, leading to a deficiency in compliance with regulations.
The facility failed to implement physician's orders for multiple residents, leading to deficiencies in care. A resident with heart failure and another with dysphagia lacked documented weights as ordered. Two residents with hypertension and heart failure did not have required blood pressure and heart rate checks documented before medication administration. Interviews confirmed the lack of documentation.
The facility failed to develop comprehensive care plans for two residents with dementia, as identified in their assessments. Despite the need to address cognitive decline being noted, there was no evidence of interventions in their care plans. The DON confirmed the lack of documentation for these care areas.
The facility failed to provide adequate grooming and hygiene services for four residents requiring assistance with ADLs. A resident with depression and osteoarthritis had long, dirty nails, while another with adult failure to thrive had long, discolored nails. A third resident with hemiplegia also had long, discolored nails, and a fourth resident with depression had disheveled hair with a large knot. The DON acknowledged that care should have been provided, and there were no documented refusals.
The facility failed to serve meals at scheduled times on the third-floor nursing unit, with meal trays arriving significantly late. Observations showed that several residents received their meals over an hour after the scheduled time, and some residents reported frequent issues with missing trays. Staff confirmed the delays and missing trays, indicating a failure to meet resident needs and preferences.
The facility failed to provide timely written notifications to residents and their representatives regarding hospital transfers, including reasons and Ombudsman information. This deficiency affected three residents who were transferred after a change in condition, with no documentation supporting that the required notifications were given. The Administrator confirmed the lack of notifications.
The facility failed to serve food at acceptable temperatures on the third floor nursing unit. Residents reported that food was often served cold, and a test tray evaluation confirmed that the service temperatures of chicken, potato wedges, and zucchini were below the acceptable range, indicating a failure to meet the facility's standards.
The facility failed to maintain sanitary conditions in the kitchen as two male dietary aides were observed preparing resident lunch trays without wearing beard restraints, violating the facility's policy on preventing foodborne illness. The Food Service Director confirmed the violation.
Failure to Follow Physician Orders for Medication and Treatment
Penalty
Summary
The facility failed to implement physician's orders for two residents, resulting in deficiencies related to medication administration and prescribed treatments. For one resident with hypertension and requiring renal dialysis, staff were ordered to administer metoprolol tartrate twice daily, withholding the medication if the systolic blood pressure (SBP) was less than 110 mmHg. However, documentation showed that the medication was administered 85 times without evidence that blood pressure was assessed prior to administration as required. Additionally, the same resident had an order for hydralazine to be given every eight hours as needed if SBP exceeded 170 mmHg, but there was no evidence that the medication was administered on five occasions when the SBP was above this threshold. Another resident with a history of stroke, diabetes, and muscle wasting had a physician's order for a compression stocking to be applied to the left lower leg in the morning and removed in the evening to address leg swelling. Multiple observations over several days revealed that the resident was seen in the hallway in a wheelchair with visible ankle swelling and without the compression stocking in place. The Director of Nursing confirmed that the compression stocking should have been applied according to the physician's order.
Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent during medication administration on two of three nursing units. During observed medication passes, there were 28 opportunities for medication administration, with two errors identified, resulting in a 7.14% error rate. One error involved a resident with atrial fibrillation, hypertension, and heart failure, who was prescribed Losartan Potassium 25 mg daily but was only administered 12.5 mg by an LPN, which was half the ordered dose. Another error involved a resident with dementia and gastroesophageal reflux disease, who was prescribed Protonix delayed release tablets, which should not be crushed; however, an LPN crushed the tablet prior to administration. The Director of Nursing confirmed that these medications were not administered according to physician orders.
Failure to Maintain Clean and Safe Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for one resident, as evidenced by direct observation and interview. During an inspection, several small black flying insects were seen around the resident's head and face while she was in bed, and four ants were found on top of the mattress. Additional ants were observed on the dresser, and large cobwebs were present on each side of the window. The floor near the air conditioning unit had a dried yellow substance, and the dresser drawer did not close properly. A family member confirmed that small insects were consistently present in the room, the yellow substance on the floor was permanent, and the dresser drawer was always difficult to close. These findings demonstrate that the facility did not maintain a clean, safe, and homelike environment for the resident, as required by state regulations.
Deficiency in Accurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for two residents, leading to a deficiency in compliance with federal and state regulations. Resident 2, diagnosed with muscle wasting and anemia, had physician's orders to cleanse the sacrum with medihoney and apply skin prep to both heels. However, the treatment administration record (TAR) for February 2025 lacked documentation of these treatments on specific dates, despite the resident confirming that the treatments were applied as ordered. Similarly, Resident 3, also diagnosed with muscle wasting and anemia, had orders to apply skin prep to both heels and a blister on the abdomen. The TAR for February 2025 showed missing documentation for these treatments on several dates, even though the resident confirmed the treatments were administered. The Director of Nursing acknowledged the failure to properly document the treatments, confirming the deficiency in maintaining complete and accurate medical records.
Plan Of Correction
This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report. 1. Resident 2 and 3 Treatments were provided as ordered. 2. An initial audit was completed for residents receiving skin prep to validate residents treatments were documented as administered. Variances were addressed at the time of the audit and placed on the facility audit tool. 3. Licensed nursing staff were educated on the documentation process for treatments. 4. DON/ designee will complete audits 3x per week x4 weeks to validate residents treatments were documented as administered. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.
Failure to Implement Physician's Orders for Multiple Residents
Penalty
Summary
The facility failed to implement physician's orders for five residents, leading to deficiencies in care. Resident 24, diagnosed with heart failure and chronic obstructive pulmonary disease, did not have daily weights documented on specified dates as ordered by the physician. Similarly, Resident 34, with dysphagia and chronic obstructive pulmonary disease, lacked documentation for weekly weights on multiple occasions. Resident 145, diagnosed with dependent edema, also had missing documentation for daily weights over several days. Additionally, the facility did not adhere to physician's orders regarding medication administration for Residents 65 and 95. Resident 65, with hypertension, was prescribed lisinopril with a condition to check systolic blood pressure before administration, but there was no documentation of this being done 45 times. Resident 95, with heart failure and diabetes, was prescribed carvedilol with conditions to check both blood pressure and heart rate before administration, yet documentation was missing for 42 instances. Interviews with the Administrator and Director of Nursing confirmed the lack of documentation for these assessments.
Failure to Address Cognitive Decline in Care Plans
Penalty
Summary
The facility failed to develop a comprehensive care plan to address the cognitive decline and dementia needs of two residents, as identified in their comprehensive assessments. Resident 61, admitted with a diagnosis of dementia, had a Minimum Data Set Care Area Assessment summary dated July 21, 2024, which indicated that cognitive decline/dementia should be addressed in the care plan. However, there was no evidence of interventions for this condition in the current care plan. Similarly, Resident 65, also diagnosed with dementia, had a Care Area Assessment summary dated October 11, 2024, noting the need to address cognitive decline/dementia in the care plan, but no interventions were documented. The Director of Nursing confirmed in an interview on November 15, 2024, that there was no documented evidence that the identified care area was addressed in the care plans of Residents 61 and 65. This deficiency is a violation of 28 Pa. Code 211.12(d)(1)(5) regarding nursing services.
Failure to Provide Adequate Grooming and Hygiene Services
Penalty
Summary
The facility failed to provide adequate grooming and hygiene services for four residents who required assistance with activities of daily living (ADLs). Resident 5, diagnosed with depression, osteoarthritis, and muscle wasting, was observed with long and dirty fingernails, despite expressing a preference for short nails and not refusing care. Resident 27, with diagnoses including adult failure to thrive and muscle wasting, was observed with long and discolored nails on multiple occasions, and her representative confirmed that her nails were not being cut regularly. Resident 81, who has hemiplegia and vertical strabismus, was also observed with long and discolored nails on his right hand, and he stated that staff had not offered to cut them. Additionally, Resident 28, diagnosed with depression and anxiety, was observed with disheveled and unkempt hair, including a large knot at the back of her head. She reported that staff did not offer assistance to wash or comb her hair during bathing. The Director of Nursing acknowledged that nail care should have been provided with bathing and as needed, and that assistance with hair care should have been offered. There were no documented refusals of care for any of these residents.
Delayed Meal Service on Third-Floor Nursing Unit
Penalty
Summary
The facility failed to ensure that meals were served at regularly scheduled times in accordance with resident needs on the third-floor nursing unit. The meal schedule indicated that the second and final meal cart delivery was set for 12:45 p.m. However, observations on November 13, 2024, revealed that the meal cart arrived at 1:10 p.m., and tray pass began at 1:20 p.m., which was 35 minutes after the scheduled time. By 1:28 p.m., the meal cart was empty, yet several residents, including Residents 33, 37, 74, 107, 119, and 139, had not received their meal trays. Further observations showed that meal trays were delivered to Residents 37, 107, 119, and 139 over an hour after the scheduled meal time, while Residents 33 and 74 received their trays over 80 minutes late. Resident 51 had previously stated that meals were often served late, and Resident 37 mentioned that his meal tray was frequently missing. Both Nurse Aide 1 and Licensed Practical Nurse 1 confirmed the delay and the absence of meal trays for some residents. This deficiency was noted under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee.
Failure to Notify Residents of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notifications to residents and their representatives regarding transfers to the hospital, including the reasons for the transfers and Ombudsman information. This deficiency was identified for three residents who were transferred to the hospital after a change in condition. Specifically, Resident 123 was transferred on two occasions, and Residents 139 and 142 were each transferred once. In each case, there was no documentation to support that the residents or their responsible parties were provided with the required written information. The Administrator confirmed in an interview that these notifications were not provided.
Failure to Serve Food at Acceptable Temperatures
Penalty
Summary
The facility failed to provide food that was palatable and at acceptable temperatures on the third floor nursing unit. This deficiency was identified through resident interviews, facility documentation review, observations, and a test tray evaluation. On October 1, 2024, residents reported that food was often served cold. A test tray evaluation conducted on the same day revealed that the service temperatures of the chicken, potato wedges, and zucchini were below the acceptable range of 115 to 135 degrees Fahrenheit, with temperatures recorded at 114.5, 113.5, and 119.1 degrees Fahrenheit, respectively. These food items were noted to be cool to taste, indicating a failure to meet the facility's standards for food temperature.
Failure to Maintain Sanitary Conditions in the Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen. During a tour of the kitchen, two male dietary aides were observed assisting on the tray line preparing resident lunch trays without wearing beard restraints, which is a violation of the facility's policy on preventing foodborne illness. The policy, dated April 3, 2024, requires beard restraints to be worn when cooking, preparing, or assembling food to prevent hair from contacting exposed food, clean equipment, utensils, and linens. The Food Service Director confirmed that the dietary aides should have had beard restraints in place as per the facility policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Langhorne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Langhorne Gardens Health & Rehabilitation Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Crestview Center | 1.9 mi | ★★★★★ | 6 | 0 |
| Statesman Health & Rehabilitation Center | 2.3 mi | ★★★★★ | 8 | 0 |
| Juniper Village At Bucks County Rehab And Skd Care | 2.9 mi | ★★★★★ | 1 | 0 |
| Chandler Hall Health Services | 3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.