F0607

J

Failure to Follow Abuse Policy, Conduct Timely Background Checks, and Protect Resident from Alleged Abuse

Saxonburg, Pennsylvania Survey Completed on 03-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its own abuse, neglect, and exploitation policy, including required criminal background checks and mandated reporting and investigation of abuse/neglect allegations. The facility’s written policy stated that all employees must have criminal background checks completed prior to hire and that records of such checks must be retained in employee files. Review of the social worker’s (Employee E1) personnel file showed a hire date of 1/27/26, but the criminal background check for this employee was not completed until 3/12/26. During an interview, the DON and NHA confirmed that this staff member began working without a completed background check, contrary to facility policy.

The deficiency also includes the facility’s failure to identify, report, and investigate an allegation of abuse/neglect involving one resident, and failure to protect that resident from the alleged perpetrators. Resident R1, who had bilateral above-knee amputations and opioid dependence and was documented as cognitively intact with a BIMS score of 15, reported that on 3/11/26 he experienced verbal and attempted physical abuse from the NHA and felt unsafe when the NHA was in the facility. The resident stated he wrote a letter detailing the events and gave it the same day to an RN supervisor (Employee E3), whom he described as the only person he trusted. The resident reported that the facility did nothing, did not investigate, and allowed the alleged perpetrators to continue working.

Multiple staff interviews corroborated that an incident occurred and that the NHA continued to work afterward. A COTA (Employee E5) stated he arrived about five minutes after the incident, described the NHA as intimidating with a short fuse, and confirmed the NHA worked the remainder of that day. The Director of Maintenance (Employee E4) confirmed he had to remove the NHA from the resident’s room to deescalate the situation and that the NHA continued to work that day. The resident’s written letter described verbal and attempted physical abuse by the NHA, a HIPAA violation involving personal information being yelled in the hall, and an LPN (Employee E2) making an obscene gesture behind a curtain and then directly to the resident when confronted. The RN supervisor (Employee E3) confirmed receiving the written concern on 3/11/26 and stated she was unsure to whom to give it because the allegation involved the NHA.

The facility failed to document or process this allegation as an incident and did not report it to the State Agency or other required entities at the time it occurred. Review of facility incident logs and information submitted to the State Agency on 3/11/26 and 3/12/26 showed no inclusion of Resident R1’s abuse/neglect allegation. The DON acknowledged being aware of a verbal altercation on 3/11/26 and stated that the NHA was asked to see the resident and that corporate instructed them not to call the police. The DON confirmed that the NHA and LPN E2 were not suspended and continued to work in the facility, and that the facility failed to timely report, investigate, notify appropriate agencies, and protect residents from further abuse/neglect related to this event. The NHA was only suspended two days after the alleged abuse/neglect occurred. These failures, combined with the lack of a timely background check for Employee E1, resulted in an immediate jeopardy situation as cited by surveyors.