Health inspection·February 20, 2025

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Based on a review of facility policies,documents, observations and staff interviews it was determined that the facility failed to provide a dignified dining experience on 2/19/25, during the lunch meal service to four of seven residents. (Resident R1, R2, R3, and R4). Findings include: A review of facility Dignity policy dated 9/25/24, indicated that residents are treated with dignity and respect at all times. During a review of facility document Residents with staff feed printed on 2/19/25, it was revealed that Resident R1 and R2 required staff to feed the resident. During an observation on 2/19/25, at 12:35 pm it was revealed that Resident R1 was laying in bed being feed by a Nursing Assistant (NA) that was standing over her at the bedside. During an interview on 2/19/25, at 12:39 Registered Dietitian (RD) Employee E1 confirmed that the NA was standing over Resident R1 while she was feeding the resident which failed to provide a dignified dining experience for the resident. During an observation at of tray delivery on 2/19/25, it was observed that the trays arrived on the nursing unit at 12:20 pm at 12:30 pm Resident R 3 was standing at the door of his room asking when he was going to receive his meal tray. He confirmed that his roommate received his meal tray a long time ago. Further observation revealed that Resident R4 had not received her meal tray and her roommate had received her meal. During an observation of meal tray service on 2/19/25, at 12:35 pm during the lunch meal service it was determined that the facility failed to properly place meal trays into the tray delivery cart to make certain that residents roomed together received their meals at the same time. During an interview on 2/19/25, at 12:40 pm RD Employee E1 confirmed that the facility failed to deliver Resident R3 and R4's meal trays on the correct delivery cart resulting in a delay of their meal tray delivery and failed to provide a dignified dining experience to Resident R3 and R4. During an observation on 2/19/25, at 12:50 pm it was revealed that Resident R2 was laying in bed and being feed by a NA that was standing over the resident while the resident was being fed. During an interview on 2/19/25, at 12:55 Registered Nurse Manager Employee E2 confirmed that by Page 1 of 5 395732 395732 02/20/2025 Heritage Care Center 5701 Phillips Avenue Pittsburgh, PA 15217

F 0557 standing over the resident while being feed the facility failed to provide a dignified dining experience for the resident. Level of Harm - Minimal harm or potential for actual harm Pa Code: 201.29(k) Resident rights Residents Affected - Some Pa Code: 207.2(a) Administrator's responsibility 395732 Page 2 of 5 395732 02/20/2025 Heritage Care Center 5701 Phillips Avenue Pittsburgh, PA 15217

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on a review of facility job descriptions and staff interviews it was determined that the facility failed to provide a qualified Food Service Director (FSD) to manage the daily operations of the Food Service Department for 99 days (11/22/24, through 2/18/25), Findings include: A review of the facility's Food Service Director job description date 9/25/24, revealed that the purpose of the FSD position is to plan, organize, develop and direct the overall operation of the Food Services department in accordance with established food service standards, policies, procedures and practices of the facility and requirements of current federal, state and local standards governing the facility and as may be directed by the Administrator to assure that quality nutritional services are provided as a daily basis and that the food services department is maintained in a clean, safe and sanitary manner. Education and Qualifications include: be a graduate of an accredited course in dietetic training approved by the American Dietetic Association or must be registered as a Food Service Director in Pennsylvania. During a tour of the Main Kitchen on 2/19/25, at 8:15 am Registered Dietitian (RD) Employee E1 confirmed that the facility currently did not employee a Food Service Director. During an interview with the Nursing Home Administrator on 2/19/25, at 1:30 pm it was confirmed that the facility has failed to provide a Full time Food Service Director to oversee the daily operations of the main kitchen since 11/24/24. During an interview on 2/20/25, at 12:50 pm the Nursing Home Administrator confirmed that the persons sharing responsibility of overseeing the daily operations of the main kitchen failed to meet the education and qualifications of a Food Service Director as required resulting in the facility failing to provide a qualified Food Service Director to oversee the daily operations of the food services department from 11/22/24. through 2/18/25. Pa Code: 211.6(c)(d) Dietary services 395732 Page 3 of 5 395732 02/20/2025 Heritage Care Center 5701 Phillips Avenue Pittsburgh, PA 15217

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policies, observations and staff interviews, it was determined that the facility failed to properly store chemicals, properly label and date food products, properly store food products, monitor and maintain records of refrigeration/freezer temperature logs to make certain refrigeration/freezers function properly, maintain the cleanliness and sanitation of the Main Kitchen. (Main Kitchen). Findings include: A review of facility Food Storage: policy date 9/25/24, revealed that Food storage areas shall be maintained in a clean, safe and sanitary manner. Cold foods will be maintained at temperatures at 41 ° F (degrees Fahrenheit) or below. All foods stored in the walk in refrigeration and freezers will be stored above the floor on shelves. Leftovers will be labeled and dated. Soaps, detergents, cleaning compounds are stored in separate storage areas. The Dining Services Managers, [NAME] or designee will check refrigerators, freezers twice daily for proper temperature maintenance. A review of facility Sanitation policy date 9/25/24, revealed that the food service area shall be maintained in a clean and sanitary manner, A tour of the Main Kitchen on 2/19/25, at 8:15 am revealed: * Dishmachine chemicals stored on the same rack of cans of applesauce and three gallon containers were being used to block the storeroom door from closing. * Food products in the storeroom failed to be dated with receiving dates * Number one cooler contained unlabeled and undated pre portioned containers of pineapple chunks and diced peaches * Number two door cooler contained undated pre portioned containers of chef salads, unlabeled and undated pre portioned containers of fruit cocktail and applesauce, undated opened containers of mayonnaise and [NAME] slaw dressing, and a tray of Indivdual unlabeled ham and cheese and turkey and cheese sandwiches on a tray dated with an expired date of 2/13/25. * Stored on the floor of the walk in refrigerator and marked with a receiving date of 2/13/25, were five cases of juice and six cases of milk. * Stored in the walk in refrigerator and freezer were food products stored out of their original case that the facility failed to properly label and date. * the cook's reach in refrigerator contained an unlabeled and undated pan of soup, an unlabeled and undated pan of cooked hamburgers and unlabeled and undated pre made sandwiches. * the exhaust hood contained a build up of grease and debris * the air vents over the cooking area contained a build up of dust and debris 395732 Page 4 of 5 395732 02/20/2025 Heritage Care Center 5701 Phillips Avenue Pittsburgh, PA 15217

F 0812 * the bulk head over food preparation tables contained a build up of dust and debris Level of Harm - Minimal harm or potential for actual harm * the stove top and grill contained a build up of food particles, food spillage and grease. Residents Affected - Many * a review of all refrigeration/freezer temperature logs revealed that the facility failed to monitor and record twice daily for proper temperature maintenance. During an interview on 2/19/25, at 8:40 am the Nursing Home Administrator and Register Dietitian Employee E1 confirmed that the facility failed to maintain the Main Kitchen in a clean, safe and sanitary manner, properly label and date food products, properly store chemicals separate from food products, and properly store food products from the floor which created the potential for food borne illness. Pa Code 211.6(c)(d)(f) Dietary services 395732 Page 5 of 5