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F0835
D

Failure to Supervise High-Risk Resident Resulting in Elopement and Immediate Jeopardy

Pittsburgh, Pennsylvania Survey Completed on 09-25-2025

Penalty

Fine: $28,020
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The Nursing Home Administrator (NHA) failed to effectively manage the facility to ensure that proper supervision was provided for residents identified as high risk for elopement. This failure resulted in a resident elopement, which created an immediate jeopardy situation. The NHA's job description required directing the day-to-day functions of the facility in accordance with federal, state, and local regulations to assure the highest degree of quality care. However, based on a review of the job description, facility and clinical records, and staff interviews, it was determined that the facility did not provide adequate supervision as required for high-risk residents. This deficiency led to a breach in the fundamental principles of treatment and care, and the facility did not ensure that residents received care in accordance with professional standards of practice and facility policies.

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