F0607

L

Systemic Failure in Abuse/Neglect Training, Screening, and Licensing Leading to Resident Neglect

Pittsburgh, Pennsylvania Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its own policies and procedures to prevent abuse, neglect, and mistreatment, specifically through required screening and training of staff. The facility’s written Abuse, Neglect, & Mistreatment policy stated that all potential employees would be screened for a history of abuse, neglect, or mistreatment through inquiries to state licensing authorities or nurse aide registries and criminal background checks, and that abuse, neglect, and misappropriation education would be completed upon hire and at least annually for all employees. Despite this, review of employee files showed that one LPN had no documentation of a pre-employment background check, and an out-of-state scheduler had only a state background check with no evidence of the required FBI background check. Further review revealed that 26 facility employees had no pre-employment background check documented in their files until checks were completed later.

The facility also failed to ensure that staff held current, valid licenses and that these were verified prior to and during employment. File reviews showed that multiple staff members, including two NAs, two RNs, and the DON, had expired licenses or no license on file. Additional audits identified two NAs who had been working with expired licenses. The NHA acknowledged not knowing the process for checking expired licenses. These lapses occurred despite the policy requirement that screening include inquiries into state licensing authorities and nurse aide registries to identify any disciplinary actions.

In addition, the facility did not provide required annual abuse and neglect prevention training to its staff. Review of training records and staff files showed that five of seven staff members later identified as alleged perpetrators in a reported neglect incident had no documentation of annual abuse and neglect education for the current year. A broader review confirmed that none of the 90 current facility employees had documentation of annual abuse and neglect training for a 12‑month period. The Human Resources Director stated that no annual education had been completed from January through the date she started working at the facility, and the list of 2025 education topics did not include abuse and neglect. Staff interviews corroborated that while some employees had recently received abuse and neglect education, several indicated it had been a long time since they received such training at this facility or that they received it only at other jobs. These combined failures in training, background checks, and license verification resulted in an Immediate Jeopardy determination for all residents.

The neglect incident that triggered identification of alleged perpetrators involved 12 residents on the second floor who did not receive any morning care because no staff were assigned to rooms 209-A through 217-B. A NA reported that these residents had not received morning care, and surveyors informed the NHA and DON twice during the same day that the 12 residents still had not received any morning care. The NHA confirmed that seven staff members, including NAs, an LPN, RNs, the DON, and the NHA, were identified as alleged perpetrators of neglect related to this incident. The facility’s own policy defined neglect as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, including when staff are aware or should be aware of residents’ care needs but do not meet them due to factors such as lack of training, insufficient staffing, lack of supplies, or lack of knowledge of resident needs. The survey findings linked the lack of required abuse/neglect training, incomplete background checks, and unverified or expired licenses to this neglect event and the resulting Immediate Jeopardy for all residents.

Surveyors confirmed through interviews with successive NHAs that the facility failed to ensure annual abuse and neglect prevention training for the majority of staff, failed to complete required pre-employment criminal background checks for multiple employees, failed to conduct an FBI background check for an out-of-state employee, and failed to verify current, valid licenses and any disciplinary actions prior to employment for several staff members. These findings were cited under Pennsylvania regulatory provisions related to the responsibility of the licensee, management, and personnel policies and procedures. The Immediate Jeopardy was based on these systemic failures in screening, training, and oversight, combined with the documented incident in which 12 residents did not receive morning care due to lack of staff assignment.

Removal Plan

• Facility has reviewed current policy on abuse and neglect.
• All current facility staff including agency will receive training on current facility policy for abuse and neglect.
• Those who do not complete education will not be permitted to work until education is completed.
• All current facility employee files, including agency, will be reviewed to ensure that they have education on facility policy for abuse and neglect, a current and active license on file, and a background check present in their file.
• Missing items that are identified in audit will be immediately corrected.
• Facility will audit all new hire and all new agency staff files to ensure that files contain evidence of abuse education, a current and active license, and a background check.
• Results of the audit will be reported to the Ad Hoc Quality Assurance Performance Improvement Committee.