F0835

E

Failure of DON to Investigate Multiple Allegations of Misappropriation and Narcotic Diversion

Pittsburgh, Pennsylvania Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the DON’s failure to timely and effectively manage and investigate five allegations of misappropriation of resident belongings, including narcotic diversion, involving five residents (R1, R2, R3, R4, and R5). The DON’s job description dated 12/9/24 required him to plan, organize, develop, and direct the overall operations of the nursing services department, establish facility policies and procedures, ensure appropriate care and services, perform rounds to observe residents, and monitor for allegations of potential abuse or neglect while participating in the investigative process. Despite these defined responsibilities, the facility did not have investigations completed for the reported misappropriation incidents that included diversion of narcotic medications.

During an interview on 2/25/26 at 3:15 p.m., the DON initially stated that he had the investigation of the incident in his office and would provide a copy to the state agency. Later that same day at 4:45 p.m., when asked directly if he had an investigation concerning the narcotic diversion, the DON replied that he did not and confirmed he had failed to have an investigation for the misappropriation of resident belongings that included narcotic diversion for all five residents. On 2/26/26 at 3:00 p.m., the NHA confirmed that the DON failed to timely and effectively manage these five allegations of misappropriation of resident belongings, which included narcotic diversion. These failures were cited under 28 Pa. Code 201.14(a), 201.18(b)(1)(3)(e)(1), and 211.12(d)(1)(2)(3)(5).