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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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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 April 8, 2025, Oak Ridge Rehabilitation & Healthcare Center, was not in compliance with the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(b), 416.54(b), 418.113(b), 441.184(b), 482.15(b), 483.475(b), 483.73(b), 484.102(b), 485.542(b), 485.625(b), 485.68(b), 485.727(b), 485.920(b), 486.360(b), 491.12(b), 494.62(b) STANDARD Development of EP Policies and Procedures:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.

§403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b).

(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years.

*[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually.

*Additional Requirements for PACE and ESRD Facilities:

*[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years.

*[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area.

Observations:
Name: - Component: -- - Tag: 0013

Based on documentation review and interview, it was determined the facility failed to maintain the Emergency Preparedness Plan in one instance, affecting two of two floors.

Findings include:

1. Observation on April 8, 2025, at 12:00 p.m., revealed the required annual review of the EP Plan had not been performed since 12/14/2023.

Exit interview on April 8, 2025, between 12:25 p.m., and 12:35 p.m., with the Facilities Manager and the Regional Facilities Manager, confirmed emergency preparedness plan deficiency.

Plan of Correction - To be completed: 04/29/2025

1. The EP Plan has been reviewed and signed effective 4/8/25
2. Director of Maintenance will validate the EP Manual is signed appropriately
3. Nursing Home Administrator will re educate the Director of Maintenance on proper annual review of EP Manuel
4. Director of Maintenance will conduct monthly audits for 3 months to validate EP Manual is properly updated with annual review. Findings of these audits will be reviewed by Quality Assurance Performance Improvement Committee and changes will be made as needed.

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 April 8, 2025, 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 Sprinkler System - Maintenance and Testing:

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.

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in four locations, affecting two of two floors.

Findings include:

1. Observation on April 8, 2025, between 11:15 a.m., and 11:55 a.m., revealed the following:

a. 11:15 a.m., first floor Electrical Room lacked ceiling tiles.
b. 11:30 a.m., first floor Social Services lacked a ceiling tile.
c. 11:50 a.m., second floor Hot Room lacked a ceiling tile.
d. 11:55 a.m., BX was located atop automatic sprinkler piping within the second floor Hot Room.

Exit interview on April 8, 2025, between 12:25 p.m., and 12:35 p.m., with the Facilities Manager and the Regional Facilities Manager, confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 04/29/2025

1. Electrical room, social service room, second floor hot room, and BX ceiling tiles have been corrected
2. Director of Maintenance has conducted a facility audit to validate ceiling tiles are not lacking.
3. Nursing Home Administrator will re educate director of Maintenance on validating ceiling tiles are not lacking
4. Director of Maintenance will conduct monthly audits for 3 months to validate ceiling tiles are in proper places. Findings of these audits will be reviewed by Quality Assurance Performance Improvement Committee and changes will be made as needed.

NFPA 101 STANDARD Corridor - Doors:

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 April 8, 2025, between 11:31 a.m., and 11:42 a.m., revealed the following corridor doors lacked positive latching capabilities:

a. 11:31 a.m., first floor Main Dining Room.
b. 11:42 a.m., first floor Lounge.

Exit interview on April 8, 2025, between 12:25 p.m., and 12:35 p.m., with the Facilities Manager and the Regional Facilities Manager, confirmed the corridor opening deficiencies.

Plan of Correction - To be completed: 04/29/2025

1. First floor main dining room and first floor lounge, positive latches have been corrected
2. Director of Maintenance will conduct an initial audit to determine the positive latches are in place
3. Nursing Home Administrator will re educate the Director of Maintenance on validating positive latches are in place
4. Director of Maintenance will conduct monthly audits for 3 months to validate positive latches are in place. Findings of these audits will be reviewed by Quality Assurance Performance Improvement Committee and changes will be made as needed.

NFPA 101 STANDARD Electrical Equipment - Other:

Electrical Equipment - Other
List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 10 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0919

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

Findings include:

1. Observation on April 8, 2025, at 11:12 a.m., revealed an unsecured junction box, located within the first floor Mechanical Room.

Exit interview on April 8, 2025, between 12:25 p.m., and 12:35 p.m., with the Facilities Manager and the Regional Facilities Manager, confirmed the electrical systems deficiency.

Plan of Correction - To be completed: 04/29/2025

1. Unsecured junction box has been secured on first floor mechanical room
2. Director of Maintenance has will conduct an initial audit to determine that junction boxes are secure.
3. Nursing Home Administrator will re-educate the Director of Maintenance on validating junction boxes are secure
4. Director of Maintenance will conduct monthly audits for 3 months to validate junction boxes are secure. Findings of these audits will be reviewed by Quality Assurance Performance Improvement Committee and changes will be made as needed.

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