Oak Ridge Rehabilitation & Healthcare Center

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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