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

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OAK RIDGE REHABILITATION & HEALTHCARE CENTER
Inspection Results For:

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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 February 18, 2026, 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 February 18, 2026, 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 ensure that exit access was always being maintained readily accessible, affecting one of two floors.

Findings include:

1. Observation on February 18, 2026, at 10:24 am, 3rd floor, revealed the exit door to the outside, near resident room 308, could only be opened after several forceful tries and continued difficult to open after the initial opening.

Exit interview with the Facility Administrator and Facilities Manager on February 18, 2026, at 11:15 am, confirmed the door opening difficulty.




 Plan of Correction - To be completed: 03/12/2026

1.3rd floor exit door was adjusted to open and close
2.Maintenance conducted an audit of exit doors to verify they operate properly
3.NHA will reeducate Maintenance on keeping the exit doors working properly.
4.Maintenance/Designee will conduct audits of exit doors to verify they are not propped open weekly x4 and monthly x3 and report findings to monthly QAPI committee.

NFPA 101 STANDARD Stairways and Smokeproof Enclosures: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.
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0225

Based on observation and interview, it was determined that fire rated enclosures of exit components were not being protected to meet the standard of NFPA 80 2010 Edition, affecting one of two floors.

Findings include:

1. Observation on February 18, 2026, at 10:42 am, 1st floor, East stairwell tower door 4 failed to fully close into frame when tested.

Exit interview with the Facility Administrator and Facilities Manager on February 18, 2026, at 11:15 am, confirmed the door failed to fully close into frame.




 Plan of Correction - To be completed: 03/12/2026

1. 1st floor East stairwell tower door 4 has been adjusted to open and close
2. Maintenance conducted an audit of exit doors to verify they operate properly
3. NHA will reeducate Maintenance on keeping the exit doors working properly.
4. Maintenance/Designee will conduct audits of exit doors to verify they are not propped open weekly x4 and monthly x3 and report findings to monthly QAPI committee.

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 hazardous area door openings in two locations, affecting two of two floors.

Findings include:

1. Observation on February 18, 2026, between 10:32 am, and 10:52 am, revealed the following:

a. At 10:32 am, Laundry, Soiled Linen room door lacked positive latching hardware.
b. At 10:52 am, 1st floor, Mechanical Room door near dietary failed to fully close and latch into frame when tested.

Exit interview with the Facility Administrator and Facilities Manager on February 18, 2026, at 11:15 am, confirmed the hazardous area door deficiencies.




 Plan of Correction - To be completed: 03/12/2026

1. Laundry soiled linen room door positive latching hardware was installed, 1st floor mechanical room door was adjusted to fully close and latch into frame
2. Maintenance conducted an audit of exit doors to verify they operate properly
3. NHA will reeducate Maintenance on keeping the doors working properly.
4. Maintenance/Designee will conduct audits of exit doors to verify they are not propped open weekly x4 and monthly x3 and report findings to monthly QAPI committee.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance: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.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on review of documentation and interview, it was determined the facility failed to maintain the fire alarm system for the entire facility.

Findings include:

1. Review of documentation on February 18, 2026, between 9:30 am, and 10:15 am, revealed the facility lacked documentation that the annual functional test was conducted within the last 12 months.

Exit interview with the Facility Administrator and Facilities Manager on February 18, 2026, at 11:15 am, confirmed the lack of the annual functional fire alarm test.




 Plan of Correction - To be completed: 03/12/2026

1. Vendor was out to complete annual fire function test
2. Maintenance conducted an audit of fire inspections to verify they are timely.
3.NHA will reeducate Maintenance on timely inspections.
4.Maintenance/Designee will conduct audits to verify timely inspections are completed of annual functional tests weekly x4 and monthly x3 and report findings to monthly QAPI committee.

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 openings in two locations, affecting one of two floors.

Findings include:

1. Observation on February 18, 2026, between 10:27 am, and 10:44 am, revealed the following:

a. At 10:27 am, 2nd floor, Resident Room 326 door failed to latch into the frame.
b. At 10:44 am, 2nd floor, Dining Room doors failed to latch into the frame.

Exit interview with the Facility Administrator and Facilities Manager on February 18, 2026, at 11:15 am, confirmed the corridor doors failed to latch when tested.




 Plan of Correction - To be completed: 03/12/2026

1.The 2nd floor resident room door 326 and 2nd floor dining room doors were adjusted to latch.
2.Maintenance conducted an audit resident room doors to verify proper latching and dining room doors to verify proper latching
3.NHA will reeducate Maintenance on maintaining proper operation of doors
4.Maintenance/Designee will conduct random door audits weekly x4 and monthly x3 and report findings to monthly QAPI committee.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors in one location, affecting one of two floors.

Findings include:

1. Observation on February 18, 2026, at 10:59 am, revealed the 1st floor smoke barrier doors located near resident room 101 failed to latch into frame when released from the hold open devices. (Right Leaf)

Exit interview with the Facility Administrator and Facilities Manager on February 18, 2026, at 11:15 am, confirmed the smoke barrier doors failed to latch when tested.





 Plan of Correction - To be completed: 03/12/2026

1.1st floor smoke barrier door was adjusted so the latched into frame when closed.
2. Maintenance conducted an audit resident room doors to verify proper latching and dining room doors to verify proper latching
3.Maintenance will be reeducated maintain proper operation of doors
4.Maintenance/Designee will conduct random door audits weekly x4 and monthly x3 and report findings to monthly QAPI committee.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag: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.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, the facility failed to properly secure oxygen cylinders in one location, affecting one of two floors.

Findings include:

1. Observation on February 18, 2026, at 10:18 am, revealed one oxygen "E" cylinder, being stored in the 3rd floor oxygen storage room, was being stored on the floor without support.

Exit interview with the Facility Administrator and Facilities Manager on February 18, 2026, at 11:15 am, confirmed the door opening difficulty.




 Plan of Correction - To be completed: 03/12/2026

1.E cylinder was placed in proper storage cart
2. NHA/Designee will conduct an audit of 0xygen storage for proper storage of tanks
3.NHA will reeducate Staff on proper oxygen storage
4.NHA will conduct random audits of oxygen storage to verify E cylinders are stored properly weekly x4 and monthly x3 and report findings to monthly QAPI committee.


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