Heritage Care Center: Dialysis Orders Missing for Patients - PA
Inspectors reviewed the clinical records of both residents and found the same problem in each file. The facility's own periodic assessments, called Minimum Data Sets, documented that both residents were receiving dialysis as part of their care at the facility. The physician orders told a different story. Neither resident had an active order for dialysis on file.
For the first resident, identified in the report as Resident R2, the MDS dated April 29, 2025, listed diagnoses of end-stage kidney disease, diabetes, and chronic kidney disease. A physician order dated July 31, 2025, showed no active dialysis order.
The second resident, Resident R3, had an MDS dated July 28, 2025, also listing end-stage kidney disease and diabetes. A physician order dated July 25, 2025, three days before that assessment, likewise contained no active order for dialysis.
In both cases, the facility's own documentation confirmed the treatment was happening. The orders required to authorize it were not there.
The Director of Nursing, interviewed the following day on August 19 at 2:00 p.m., confirmed that the physician orders for both residents failed to include a dialysis order.
End-stage kidney disease is a permanent, life-sustaining condition. The kidneys have lost nearly all function, and dialysis, which filters waste and fluid from the blood that the kidneys can no longer process, is not optional care. Missing it, or disrupting it, carries serious consequences. The inspection report classified the harm level as minimal harm or potential for actual harm, meaning inspectors did not find evidence that either resident had been denied treatment, but the paperwork that would have governed and tracked that treatment was absent.
What the records show is a facility that was documenting dialysis as an ongoing service in its care assessments while simultaneously maintaining physician order sheets that did not authorize it. The two sets of documents, both generated by the facility, pointed in opposite directions.
The inspection was triggered by a complaint. The report does not identify who filed it or what specifically prompted it.
Heritage Care Center is located at 5701 Phillips Avenue in Pittsburgh. The deficiency was cited under Pennsylvania health code provisions covering licensee responsibility, medical records, and nursing services.
The Director of Nursing's confirmation on August 19 was the only staff interview included in the report. No explanation was offered for how the orders came to be missing, how long they had been absent, or whether anyone at the facility had noticed the discrepancy before inspectors arrived.
Both residents, their kidneys failing, were relying on a machine to do what their bodies could no longer do. Whether the orders were ever written and simply not maintained in the record, or were never written at all, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heritage Care Center from 2025-08-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
HERITAGE CARE CENTER in PITTSBURGH, PA was cited for violations during a health inspection on August 18, 2025.
Inspectors reviewed the clinical records of both residents and found the same problem in each file.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.