Health inspection·August 18, 2025

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 R1 and R4).Findings include:Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE].Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 7/7/25, indicated that 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 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 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 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 R4 was admitted to the facility on [DATE].Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 5/26/25, indicated that 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 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 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 R1, R4). 28 Pa. Code: 211.12(d)(1)(5) Nursing services. Residents Affected - Few Page 1 of 3 395732 395732 08/18/2025 Heritage Care Center 5701 Phillips Avenue Pittsburgh, PA 15217

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 R2 and R3).Findings include: Review of the clinical record indicated that Resident R2 was admitted to the facility on [DATE].Review of 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 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 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 R3 was admitted to the facility on [DATE].Review of 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 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 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 395732 Page 2 of 3 395732 08/18/2025 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. 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. 395732 Page 3 of 3