Oxford Rehabilitation And Healthcare Center
OXFORD REHABILITATION AND HEALTHCARE CENTER in LANGHORNE, PA — inspection on November 14, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
CFR 483.25 Quality of Care
Previously cited 11/15/24 28 Pa.
Code 211.10(d) Resident care policies.
28 Pa.
Code 211.12(d)(1)(5) Nursing services.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/14/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Oxford Rehabilitation and Healthcare Center
300 East Winchester Ave Langhorne, PA 19047
SUMMARY STATEMENT OF DEFICIENCIES
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to maintain a medication error rate of less than five percent (%) during medication administration on two of three nursing units. (1st and 2nd floor)Findings include: Observations of medication administration on November 13, 2025, from 7:30 a.m. to 11:30 a.m., and November 14, 2025, from 9:30 a.m. to 10:00 a.m., revealed 28 medication opportunities with two medication errors that resulted in a medication administration error rate of 7.14%.
Clinical record review revealed that Resident 51 had diagnoses that included atrial fibrillation (fast heart rate), hypertension, and heart failure. A physician's order dated November 8, 2025, directed staff to administer Losartan Potassium 25 milligrams (mg) daily.
Observation of the medication pass on November 13, 2025, at 11:03 a.m., revealed that Licensed Practical (LPN) 1 administered a half tablet of losartan potassium to the resident, which was only 12.5 mg, half of the dose ordered by the physician.
Clinical record review revealed that Resident 191 had diagnoses that included dementia and gastroesophageal reflux disease. A physician's order dated November 6, 2024, directed staff to administer Protonix delayed release tablet (a medication for gastroesophageal reflux disease). A review of the administration instructions for Protonix delayed release tablet revealed that the medication was not to be crushed.
Observation of the medication pass on November 13, 2025, at 7:30 a.m., revealed that LPN 2 crushed the Protonix delayed release tablet prior to administration. In an interview on November 14, 2025, at 12:49 p.m., the Director of Nursing confirmed the medications were not administered per the physician's orders. 28 Pa.
Code 211.12(d)(1)(5) Nursing services.
Facility ID: