Oak Ridge Rehabilitation & Healthcare Center
OAK RIDGE REHABILITATION & HEALTHCARE CENTER in TAYLOR, PA — inspection on September 24, 2025.
Found 1 citation. 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
her chain of command. An interview with Employee 3, RN Supervisor, conducted on September 24, 2025, at 10:35 AM, confirmed she was the RN Supervisor on duty on September 12, 2025.
Employee 3 stated she was told about the incident by Employee 4, the transportation driver, later that evening at the end of her working shift around 7:00PM).
Employee 3 stated she believed the information was a rumor and did not report it to the Nursing Home Administrator (NHA) or the Director of Nursing (DON).
Employee 3 further stated she was not directly informed by Employee 2 about the incident. An interview with Employee 4 (Transportation Driver) conducted September 24, 2025, at 11:16 AM revealed on September 12, 2025, Employee 4 arrived at the outside cardiology facility to transport Resident 1 back to her facility.
Employee 4 stated upon arrival at the cardiology office he witnessed Resident 1, Employee 1 NA, and the [NAME] driver outside of the facility.
Employee 4 stated the [NAME] driver informed him Resident 1 was witnessed to be propelling herself out of the facility when the [NAME] driver asked her where she was going.
While the [NAME] driver was questioning the resident, Employee 1 NA came running out of the building to the resident.
The [NAME] driver stated Employee 1 NA was using the restroom when the resident began to wheel herself out of the facility but was stopped.
Employee 4, transportation driver further stated upon return to the facility he told Employee 3 RN Supervisor about the incident but did not report the information to the NHA or the DON. An interview with the DON on September 24, 2025, at 11:30 AM, revealed she was not made aware of the incident involving Resident 1 until the survey team's investigation.
Despite staff interviews and statements, the facility failed to implement its written abuse policy by not ensuring the incident was reported to administration, by not initiating an immediate investigation, and by not collecting statements from all parties involved.
The failure to investigate whether neglect (defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress) occurred placed Resident 1 at risk for further neglect, elopement, or harm. 28 Pa.
Code 201.14 (a)(c) Responsibility of licensee 28 Pa.
Code 201.18(e)(1) Management 28 Pa.
Code 201.29 (a)(c) Resident Rights 28 Pa.
Code 211.10(c)(d) Resident Care policies. 28 Pa.
Code 211.12 (c)Nursing Services
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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.