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:
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.