Pennsylvania Department of Health
OAK RIDGE REHABILITATION & HEALTHCARE CENTER
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
OAK RIDGE REHABILITATION & HEALTHCARE CENTER
Inspection Results For:

There are  47 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
OAK RIDGE REHABILITATION & HEALTHCARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on December 26, 2023, at Oak Ridge Rehabilitation & Healthcare Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.





 Plan of Correction:


Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID# 201302
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on December 26, 2023, it was determined that Oak Ridge Rehabilitation & Healthcare Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.70(a).

This is a two story, Type II (000), unprotected, noncombustible, fully sprinklered building.



 Plan of Correction:


NFPA 101 STANDARD Means of Egress - General:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain means of egress in two locations on one of two floors.

Findings include:

1. Observation on December 26, 2023, between 12:30 pm, and 12:45 pm, revealed the following:

a. At 12:30 pm, the exit door near the elevator room required excess force to open.
b. At 12:45 pm, the the dry storage room near the walk-in cooler had a hasp lock installed that would lock the door from egress if in the room.

Interview at the time of the exit conference with the Regional Director of Plant Operations and facility maintenance representative on December 26, 2023, at 1:30 pm, confirmed the egress defiencies.





 Plan of Correction - To be completed: 01/19/2024

Step 1
Service is scheduled on 1/12/24 to correct deficiencies identified with door near elevator.
Hasp lock was removed from dry storage room door at the time of survey.

Step 2
To identify other areas with the potential to be effected, the maintenance director or designee completed a baseline observation audit of all exit doors and storage room doors to ensure that doors opened easily and did not require excess force, and did not have unapproved hasp locks that would prevent egress in an emergency.

Step 3
To prevent this from reoccurring, the maintenance director was provided education regarding means of egress and the importance of continuously maintaining doors from being free from obstruction to full use in case of emergency.

Step 4
To monitor and maintain ongoing compliance, the maintenance director or designee will complete random observation audits of exit and storage room doors weekly for 4 weeks, then monthly for 2 months to ensure doors opened easily and did not have unapproved hasp locks that would prevent means of egress in an emergency.

NFPA 101 STANDARD Hazardous Areas - Enclosure:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain doors to hazardous areas on one of two floors.

Findings include:

1. Observation on December 26, 2023 at 12:10 pm, revealed the laundry room door near the time clock had gaps in excess of required tolerance while latched in the frame.

Interview at the time of the exit conference with the Regional Director of Plant Operations and facility maintenance representative on December 26, 2023, at 1:30 pm, confirmed the door was out of tolerance.




 Plan of Correction - To be completed: 01/19/2024

Step 1
Laundry room door near the time clock that had gaps was corrected by maintenance staff at the time of survey.

Step 2
To identify others with the potential to be effected, the maintenance director or designee completed a baseline observation audit of doors in the facility to ensure that there were no gaps in excess of required tolerance while latched in frame

Step 3
To prevent this from reoccurring, the maintenance director or designee was provided education regarding the importance of ensuring there were no gaps indoors in excess of required tolerance.

Step 4
To monitor and maintain ongoing compliance, the maintenance director or designee will complete random observation audits of facility doors weekly for 4 weeks, the monthly for 2 months to ensure that there are no gaps in excess of required tolerance.

NFPA 101 STANDARD Corridor - Doors:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors on one of two floors.

Findings include:

1. Observation on December 26, 2023, at 11:55 am, revealed the door to room 326 failed to latch in the frame.

Interview at the time of the exit conference with the Regional Director of Plant Operations and facility maintenance representative on December 26, 2023, at 1:30 pm, confirmed the door lacked positive latching.





 Plan of Correction - To be completed: 01/19/2024

Step 1
Door of room 326 was corrected by maintenance staff at the time of survey.

Step 2
To identify other areas with the potential to be effected, the maintenance director or designee will complete a baseline observation audit to ensure that all resident room doors latch into frame and corrected if necessary

Step 3
To prevent this from reoccurring, the maintenance director was provided education regarding the importance of ensure that all resident room doors latch into frame

Step 4
To monitor and maintain ongoing compliance, the maintenance director or designee will complete random observation audits 5 day per week for 4 weeks then monthly for 2 months to ensure that all resident room doors latch in to frame without issues.


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port