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Complaint Investigation

Heritage Care Center

Inspection Date: August 18, 2025
Total Violations 3
Facility ID 395732
Location PITTSBURGH, PA
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Inspection Findings

F-Tag F0686

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

review of resident clinical records and staff interview, it was determined that the facility failed to accurately assess pressure ulcers for two of seven residents (Resident Resident R1 and Resident R4).Findings include:Review of the clinical record indicated that Resident Resident R1 was admitted to the facility on [DATE REDACTED].Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 7/7/25, indicated that Resident Resident R1 had diagnoses that included history of chronic obstructive pulmonary disease (a progressive lung disease that makes breathing increasingly difficult), hypertension and anxiety.Review of Resident Resident R1 Wound Assessment report dated 8/15/25, resident has an unstageable pressure ulcer on right later half acquired 7/2/25.Review of a physician order dated 7/7/25, indicated to cleanse with wound cleanser, apply betadine to base of thewound, leave open to air, change Q Shift. Review of Resident Resident R1's July TAR indicated the treatment was not documented as completed on 7/11/25, 7/12/25, 713/25, 7/16/25, 7/18/25, 7/19/25, 7/27/25, 7/27/25 and 7/30/25.Review of Resident Resident R1's August TAR indicated the treatment was not documented as completed on8/1/25, 8/3/25, 8/4/25, 8/9/25, 8/10/25 and 8/13/25. Review of the clinical

record indicated that Resident Resident R4 was admitted to the facility on [DATE REDACTED].Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 5/26/25, indicated that Resident Resident R4 had diagnoses that included history of chronic obstructive postlaminectomy syndrome (a condition characterized by persistent pain in the neck or back following spinal surgery), diabetes mellitus and morbid obesity.Review of Resident Resident R4 Wound Assessment report dated 6/4/25, resident had a lumbar spine surgical wound acquired 5/22/25.Review of a physician order dated 6/1/25, indicated to cleanse with wound cleanser, secure with Bordered gauze, change daily, day shift.Review of Resident Resident R4's June TAR indicated the treatment was not documented as completed on 6/17/25, 6/21/25, 6/22/25, 6/23/25, 6/24/25, 6/25/25 and 6/26/25.During an

interview on 8/18/25, at 2:00 p.m. the Director of Nursing confirmed the facility failed to complete treatments as ordered for two of seven residents (Resident Resident R1, Resident R4). 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Heritage Care Center

5701 Phillips Avenue Pittsburgh, PA 15217

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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F-Tag F0698

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0698

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

review of resident clinical records and staff interview it was determined the facility failed to have active physician orders for dialysis for two of two residents (Resident Resident R2 and Resident R3).Findings include: Review of the clinical record indicated that Resident Resident R2 was admitted to the facility on [DATE REDACTED].Review of Resident Resident R2's Minimum Data Set (MDS- a periodic assessment of care needs) dated 4/29/25, indicated with the diagnoses of end stage kidney disease (a condition where the kidney reaches advanced state of loss of function), diabetes mellitus (a chronic metabolic disease characterized by high blood sugar levels), and chronic kidney disease. Review of Resident Resident R2's MDS Section O for Special Treatments and Procedures.

J1 Dialysis indicated resident was receiving dialysis as a resident at the facility. Review of Resident R2's physician order dated 7/31/25, indicated the resident has no active order for dialysis.Review of the clinical record indicated that Resident Resident R3 was admitted to the facility on [DATE REDACTED].Review of Resident Resident R3's Minimum Data Set (MDS- a periodic assessment of care needs) dated 7/28/25, indicated with the diagnoses of end stage kidney disease (a condition where the kidney reaches advanced state of loss of function), diabetes mellitus (a chronic metabolic disease characterized by high blood sugar levels), and anxiety disease. Review of Resident Rs's MDS Section O for Special Treatments and Procedures. J1 Dialysis indicated resident was receiving dialysis as a resident at the facility. Review of Resident R3's physician order dated 7/25/25, indicated the resident has no active order for dialysis.Interview on 8/19/25, at 2:00 p.m. the Director of Nursing confirmed Resident Resident R3 and 4's physician orders failed to include an order for dialysis. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.5(f) Medical records.28 Pa. Code: 211.12(c)(d)(1)(3)(5) Nursing services.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Heritage Care Center

5701 Phillips Avenue Pittsburgh, PA 15217

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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F-Tag F0812

Nutrition and Dietary Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Based on observations and staff interview, it was determined that the facility failed to properly store food products and failed to maintain sanitary conditions which created the potential for cross contamination (Main Kitchen). Findings include: During an observation of the main designated kitchen on 8/18/25, at 10:30 a.m. the following was observed:- 1 container of mashed potatoes, no cover - 1 container of food thickener, no cover, not labelled, no date - Food Slicer: dried food, brown debris- Roucoup: dried food, debris - Steamer: food debris- bottom storage shelving of steam table: food debris- wall, ceiling beside clean side of dishwasher, brown debris During an interview on 8/18/25, Dietary Manager Employee E1 confirmed that the facility failed to properly store food products and maintain sanitary conditions in the main kitchen which created the potential for cross contamination. 28 Pa. Code: 201.18(b)(1) Management.28 Pa.

Code: 211.6(c) Dietary services.28 Pa. Code: 201.14(a) Responsibility of licensee.

Event ID:

Facility ID:

If continuation sheet

📋 Inspection Summary

HERITAGE CARE CENTER in PITTSBURGH, PA inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PITTSBURGH, PA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from HERITAGE CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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