Inspection visit
Health inspection
30 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 30 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0554
Allow residents to self-administer drugs if determined clinically appropriate.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy, review of clinical records, observations and staff interview, it was determined that
the facility failed to determine whether it was safe to self-administer medications for one of six residents
(Resident R42).Based on review of facility policy, review of clinical records, observations and staff interview,
it was determined that the facility failed to determine whether it was safe to self-administer medications for
one of six residents (Resident R42). Findings include: Review of the facility policy Resident
Self-Administration of Medications dated 10/7/25, indicated residents in the facility who wish to
self-administer their medications may do so if the interdisciplinary team has determined that this practice is
clinically appropriate. Assessments will include addressing the following and documenting in the care plan:
storage of the medication, responsible party for storage of medication, documenting the administration of
drugs, and location of where the drugs will be administered. Review of the admission record indicated
Resident R42 was admitted to the facility on [DATE]. Review of Resident R42's Minimum Data Set (MDS- a
periodic assessment of care needs) dated 10/13/25, indicated the diagnoses anxiety (intense, excessive,
and persistent worry and fear about everyday situations), depression, and post-traumatic stress disorder
(PTSD). Observation on 11/17/25, at 9:45 a.m. Resident R42 was in bed with two unidentified medications
on the bedside table. Interview on 11/17/25, at 10:00 a.m. Registered Nurse (RN) Employee E1 confirmed
the medications were left at bedside and that Resident R42 did not have documentation to determine
whether it was safe to self-administer medications. Interview on 11/17/25, at 2:30 p.m. the Director of
Nursing confirmed the medications were stored in the resident room inappropriately and that the facility
failed to determine whether it was safe to self-administer medications for one of six residents (Resident
R42). 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
Page 1 of 40
Event ID:
395732
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy, observations, and resident and staff interviews, it was determined that the facility
failed to assess and accommodate a resident's request for enabler rails (Resident R105).Findings
include:Review of the facility policy Accommodation of Needs dated 10/7/25, indicated the facility's
environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving
safe independent functioning, dignity and well-being.Review of the admission record indicated Resident
R13 admitted to the facility on [DATE].Revies of Resident R13's Minimum Data Set (MDS - a periodic
assessment of care needs) dated 11/15/25, indicated the diagnoses of stroke (damage to the brain from an
interruption of blood supply), hemiplegia (paralysis of one side of the body), and high blood pressure.
Section C0500 indicated a Brief Interview for Mental Status (BIMS- is a screening test that aids in detecting
cognitive impairment) score of 14 - cognitively intact. Section GG0170 - A. Roll left and right: The ability to
roll from lying on back to left and right side, and return to lying on back on the bed. Indicated a score of
three - partial/moderate assistance. Helper does less than half the effort. Helper lifts, holds, or supports
trunk or limbs, but provides less than half the effort.Interview on 11/17/25, at 9:30 a.m. Resident R13 and a
family member indicated the resident would feel a lot safer and independent if the bed had rails on it to help
resident to turn side to side. When asked the reason the resident did not have any rails, the response was
that the State doesn't allow side rails.Review of the clinical record failed to provide documentation that
enabler rails were ever evaluated for Resident R13.Survey Agency (SA) informed the facility's Director of
Nursing of Resident R13's request on 11/17/25, who confirmed that the facility failed to assess and
accommodate a resident's request for enabler rails (Resident R105).28 Pa. Code: 201.14(a) Responsibility
of licensee28 Pa. Code 201.18(b)(1)(e)(2.1) Management
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395732
If continuation sheet
Page 2 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0575
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy
groups and a statement that the resident may file a complaint with the State Survey Agency.
Based on observation and staff interview, it was determined that the facility failed to post complete and
current contact information for the Adult Protective Services, State Long Term Care Ombudsman, and
correct information for the Grievance Officer on two of two nursing units (Second and Third Floor nursing
units). Findings include: During observations on 11/17/25, and 11/19/25, on the Second and Third Floor
nursing units failed to reveal the contact information for Adult Protective Services, name and email of the
State Long Term Care Ombudsman, and non - conflicting information for the Grievance Officer ( three
grievance processes posted on the second floor and four posted on the third floor) with multiple grievance
officers listed on each posting. During an interview on 11/19/25, at 3:16 p.m. Nursing Home Administrator
was informed that the facility failed to post complete and current contact information Adult Protective
Services, State Long Term Care Ombudsman, and correct information for the Grievance Officer on two of
two nursing units. 28 Pa. Code 201.14(a)Responsibility of licensee.28 Pa. Code 201.18( e)Management.
Event ID:
Facility ID:
395732
If continuation sheet
Page 3 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0576
Ensure residents have reasonable access to and privacy in their use of communication methods.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, resident and staff interview, it was determined that the facility failed to ensure all
residents had access to a resident only telephone (Second and Third floor nursing units). Findings include:
During an observation on 11/18/25, at 12:20 p.m. Resident R100 was at the nurse's station on the third
floor and asked to use the facility phone. Resident R100 stated that they do not have a phone in their room
and this is always the phone that they use to call their loved one. Resident R100 indicated that there is no
other phone to use. During an interview on 11/19/25, at 12:43 p.m. with Maintenance Director Employee
E11 confirmed that the facility does not have resident telephones for private use on the second and third
floor nursing units. 28 Pa. Code 201.14 (a) Responsibility of licensee.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395732
If continuation sheet
Page 4 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of clinical records and resident family and staff interviews it was determined that the facility failed to
notify the residents responsible party of a change in a residents nursing care status (skilled nursing care
with therapy to nursing care without therapy) for one of three residents Resident R119. Findings include:
Review of the clinical record indicated Resident 119 Was admitted to the facility on [DATE]. Review of the
admission information indicated a diagnosis of leukemia (cancer of the body's blood -forming tissues)
unspecified not having reached remission, and antineoplastic chemotherapy induced pancytopenia (low
levels of red blood cells, white blood cells, and platelets). Review of the clinical record indicated Resident
was admitted for therapy and rehabilitation and completed therapy on 10/7/2025. Review of the clinical
record for Resident R119 failed to include documentation showing Resident R119 responsible
party/emergency contacts were notified in the discharge from therapy. During two interviews on 11/20/25
and 11/21/25, at 11:00 a.m. and 10:52 a.m., indicated that neither of the responsible parties listed on
Resident R119 admit sheet and involved with Resident's care were notified of the change in condition with
Responsible party/Emergency Contact Resident R119. During an interview on 11/21/25, at 9:41 a.m.
Director of Nursing confirmed that the facility was unable to provide documentation showing they informed
the responsible party /emergency contact of completion of therapy and the facility failed to notify the
residents responsible party of a change in nursing care status. 28 Pa. Code 201.18 (b)(1) Management.28
Pa. Code201.29 (d)Resident rights.
Event ID:
Facility ID:
395732
If continuation sheet
Page 5 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy, observations, resident and staff interviews it was determined that the facility failed to
maintain a homelike environment for three of nine residents (Resident R7, R24, and R46).Findings include:
A review of the policy Homelike Environment dated 10/7/25, with a previous review date of 9/25/24,
indicated Residents are provided with a safe, clean, comfortable and homelike environment and
encouraged to use their personal belongings to the extent possible. The facility staff and management
maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike
setting. These characteristics include a clean, sanitary and orderly environment. Review of Title 42 Code of
Federal Regulations S483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable,
and homelike environment, including but not limited to receiving treatment and supports for daily living
safely. S483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly,
and comfortable interior. During an observation on 11/17/25, at 9:00 a.m., Resident R7's bathroom had
linen on the floor. Resident R7 stated she did not know that the linen was in the bathroom on the floor.
During an observation on 11/17/25, at 9:10 a.m. Resident R24's bathroom had two trash bags with clothes
on the floor and approximately 18 packages of [NAME] Wipes. Resident R24 was not in the room during
this observation. During rounds and an interview 11/17/25 at 10:00 a.m., with Registered Nurse (RN)
Employee E9 confirmed the conditions of the bathrooms for Residents R7 and R24 and that the facility
failed to provide a homelike environment. During an observation on 11/18/25, at 8:56 a.m., Resident R46
had a soiled diaper lying in his trash can in his room that emitted a foul odor, Resident R46's wife stated
she thought he was soiled but it was from the soiled diaper left in the can.During an interview on 11/18/25,
at 8:59 a.m., Licensed Practical Nurse Employee E6 removed diaper and apologized to Resident's wife and
confirmed that the facility failed to provide a homelike environment. During an interview on 11/18/25, at
10:00 a.m., the Director of Nursing confirmed that the facility failed to maintain a homelike environment for
three of nine residents (Resident R7, R24, and R46). 28 Pa. Code: 201.29(k) Resident rights.
Event ID:
Facility ID:
395732
If continuation sheet
Page 6 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0585
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must
establish a grievance policy and make prompt efforts to resolve grievances.
Based on review of facility policy, resident and staff interview it was determined that the facility failed to
follow up on resident grievances for eleven residents. Finding s include: Review of the facility policy dated
2/1/25, Skilled Nursing Facility Grievance Policy indicated: Purpose - To ensure all residents resident
representatives and responsible parties in the skilled nursing facility have the right to voice concerns, file
grievances, and receive a prompt, though, an impartial response without fear of retaliation.
Acknowledgement the grievance official will acknowledge receipt of the grievance in 3 business days. A
written decision will be issued within one week unless extenuating circumstances. Review of resident
council minutes from July 2025 to October 2025 indicated residents had on-going concerns with using land
line telephones in resident rooms and phone extensions for departments in the facility, as they were unable
to get through. During a resident group interview on 11/17/25, at 2:00 approximately Residents indicated
that they are unable to get in touch with the departments in the facility. Residents were given a list of
extensions but are unable to use the extension with the current phone system. During an interview on
11/18/25, at 1:30 p.m. Director of Activities Employee E? indicated that residents who have land lines are
not able to use the extensions, and they have been given the extensions to get in touch with the
departments. During an interview on 11/19/25, at 12:40 p.m. with Maintenance Director Employee E?
indicated that residents with land lines can use their phones to contact the departments, they would need to
call the facility number and be connected. During an interview on 11/21/25, at 9:41 a.m. Director of Nursing
was informed that the facility failed to follow up on resident grievances for on-going resident concerns. 28
Pa. Code 201.29(a) Resident rights.
Event ID:
Facility ID:
395732
If continuation sheet
Page 7 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of clinical record reviews and staff interviews, it was determined that the facility failed to initiate a
thorough investigation for incident or accidents for one of three residents (Residents R20). Findings include:
Review of clinical record indicated Resident R20 was admitted [DATE], with diagnoses which included
Alzheimer's (progressive mental deterioration), adult failure to thrive and dementia (loss of cognitive
functioning). A review of Resident R20's Minimum Data Set MDS-a periodic assessment of resident care
needs), dated 11/9/25, indicated diagnoses remained current. Review of Resident R20 nurse progress
notes dated 11/1/25 at 5:52 a.m., revealed that MD on rounds who was earlier informed of resident possibly
ingesting nonprescribed meds. Review of Resident R20 incident investigation revealed no witness
statements or statement from the nurse on R20's assignment. During an interview on 11/20/25, at 2:30 p.m.
Regional Representative Employee E13 confirmed the facility did not conduct complete investigation on
Resident R20 incident as required. 28 Pa. Code: 201.14(a) Responsibility of licensee28 Pa. Code:
201.18(b)(1)(3) Management28 Pa. Code: 211. 10(d) Resident care policies28 Pa. Code: 211.12(d)(3)
Nursing services
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395732
If continuation sheet
Page 8 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of the Resident Assessment Instrument User's Manual and clinical records, and staff interview, it
was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments
were accurate and fully completed for three of twelve residents (Resident R10, R69, and R84).Findings
include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives
instructions for completing Minimum Data Set Assessments (MDS - periodic assessment of care needs)
dated October 2024, indicated that Section C: Cognitive Patterns, Question C0100 Should Brief Interview
for Mental Status Be Conducted? (BIMS) should be coded as 0 if the resident is rarely/never understood, or
it should be coded 1, and the BIMS assessment should be completed if the resident is at least sometimes
understood. Section D: Mood, Question D0100 Should Resident Mood Interview Be Conducted? should be
coded as 0 if the resident is rarely/never understood, and or it should be coded 1, and the assessment
should be completed if the resident is at least sometimes understood. Review of the admission record
indicated Resident R10 was admitted to the facility on [DATE].Resident R10 had an MDS completed on
9/25/25. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R10 is
sometimes understood. Review of Sections C: Cognitive Patterns, Question C0100 indicated Resident R10
is rarely/never understood the BIMS assessment not completed. Review of Section D: Mood Question
D0100 was coded 1 indicating Resident R10 is at least sometimes understood. Review of the admission
record indicated Resident R69 was admitted to the facility on [DATE].Resident R69 had an MDS completed
on 9/7/25. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R69
is sometimes understood. Review of Sections C: Cognitive Patterns, Question C0100 indicated Resident
R69 is rarely/never understood the BIMS assessment not completed. Review of Section D: Mood Question
D0100 was coded 1 indicating Resident R69 is at least sometimes understood. Review of the admission
record indicated Resident R84 was admitted to the facility on [DATE].Resident R84 had an MDS completed
on 9/3/25. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R84
is sometimes understood. Review of Sections C: Cognitive Patterns, Question C0100 indicated Resident
R84 is rarely/never understood the BIMS assessment not completed. Review of Section D: Mood Question
D0100 was coded 0 indicating Resident R84 is rarely/never understood. During an interview on 11/18/25, at
approximately 9:55 a.m. Employee E13 Regional Representative confirmed that the facility failed to make
certain that comprehensive Minimum Data Set assessments were accurate and fully completed. During an
interview on 11/18/25, at approximately 10:00 a.m. the Director of Nursing confirmed that the facility failed
to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for
three of twelve residents (Resident R10, R69, and R84). 28 Pa. Code: 211.5(f) Clinical records.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395732
If continuation sheet
Page 9 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy and clinical records and staff interview, it was determined that the facility failed to
update a care plan for one of six residents (Residents R105) to accurately reflect the current status of the
resident.Findings include:Review of the facility policy Care Plans, Comprehensive Person-Centered dated
10/7/254, indicated the person-centered care plan describes services that are to be furnished to attain or
maintain the resident's highest practicable physical, mental, and psychosocial well-being including services
for each element of care.Review of Resident R105's admission record indicated she was admitted on
[DATE].Review of Resident R105's Minimum Data Set (MDS- a periodic assessment of care needs) dated
9/5/25, indicated the diagnoses of hypertension, chronic obstructive pulmonary disease (COPD- a group of
diseases that block airflow and make it hard to breathe), and obsessive compulsive disorder (OCD- mental
health condition with unwanted, recurring thoughts and repetitive behaviors).Review of Resident R105's
current physician orders indicated Apixaban (blood thinner) 5mg (milligrams) two times a day.Review of
Resident R105's care plan on 11/20/25, at 12:00 p.m. failed to include a problem, goal, or interventions for
blood thinners or the risks involved for bleeding as required.Interview on 11/20/25, at 12:05 p.m. the
Director of Nursing confirmed the facility failed to update a care plan for one of six residents (Residents
R105) to accurately reflect the current status of the resident.28 Pa. Code 211.12(d)(5) Nursing services.
Event ID:
Facility ID:
395732
If continuation sheet
Page 10 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, resident and staff interview identified that the facility failed to protect Resident R111 from
potential burn accident/incident when providing a hot pack without a Physician order and monitoring the
use /time placed and failed to provide adequate supervision for Resident R20 during med pass for one of
two nursing units.
During an observation on 11/18/25, at 8:25 a.m., Resident R111 asked the SA to go into her bedside stand
drawer and get out the hot pack and place it on her left shoulder. The SA observed the disposable hot pack
and told the resident that the nurse would be told. Resident R111 stated that the nurses always give me
them.
During a clinical record review Resident R111 was admitted to the facility on [DATE], with diagnoses which
included a stoke causing left side hemiparesis. An MDS (Minimum Data Set- a periodic assessment of
resident care needs) dated 9/8/25, indicated the diagnoses remained current.
Review of Resident R111's current physician's orders did not include use of a hot pack to Resident R111's
left shoulder.
During a clinical record review on 11/18/25, at 8:28 a.m., Licensed Practical Nurse (LPN) Employee E6
stated the resident does not have a order for a hot pack.
During an interview on 11/18/25, at 8:35 a.m., Physical Therapist Employee E14 stated that the therapy
department does not have hot packs that nursing keeps them on unit and they are disposable.
During an interview on 11/18/25, at 8:30 a.m., LPN Employee E6 confirmed that the facility did not protect
Resident R111 from the potential for accident with a burn when providing a hot pack with no physician
order or monitoring of the use/time placed on Resident R11's shoulder.
Review of the admission record indicated Resident R 20 was admitted to the facility 8/5/25.
Review of Resident R20's Minimum Data Set (MDS-periodic assessment of resident care needs) include
diagnosis of Alzheimer's (progressive mental deterioration), adult failure to thrive and dementia (loss of
cognitive functioning).
Review of Resident R20's nurse's progress notes on 11/3/25 (late entry note for 10/31) by Physician
indicated that resident ingested another resident meds that were left unattended on the med cart.
Review of R20's progress notes, indicated no nurse progress note until 11/1/25.
Review of Resident Incident Summary dated 10/31/25, indicated NA (Nurse Aide) requested nurse assist to
transfer resident to bed because she was feeling lethargic. Noted that resident could have took a sip of
medication that were mixed with water on top of medication cart.
Review of facility provided documentation indicated no statement from the nurse on R20's assignment or
any witness statements.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395732
If continuation sheet
Page 11 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0689
During an interview on 11/20/25 at 2:30 p.m. Regional Representative E13 confirmed the facility failed to
provide adequate supervision for Resident R20 as required.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395732
If continuation sheet
Page 12 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and
provide appropriate care for a resident with a feeding tube.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy, clinical record review, observation, and staff interview, it was determined that the
facility failed to ensure that residents with an enteral feeding tube (G- Tube, a tube inserted in the stomach
through the abdomen) received appropriate treatment and services to prevent potential complications for
three of four residents (Residents R60, R99, and R117).Findings include: Review of facility policy Enteral
Feedings - Safety Precautions 10/7/25, indicated preventing errors in administration staff should check the
enteral nutrition label against the order before administration. Check the following information:-Resident
name, identification, and room number.-Type of formula.-Date and time formula was prepared.-Route of
delivery.-Access site.-Method (pump, gravity, syringe).-Rate of administration (milliliters/hour)-On the
formula label document initials, date and time the formula was hung and initial that the label was checked
against the order.Review of the admission record indicated Resident R60 admitted to the facility on [DATE].
Review of Resident R60's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/30/25,
indicated diagnoses of malnutrition (body doesn't receive enough calories or the right balance of nutrients
to stay healthy), schizophrenia (characterized by thoughts or experiences that seem out of touch with
reality, and anemia (the blood doesn't have enough healthy red blood cells).Review of Resident R60's
physician order 10/24/25, indicated enteral feed order two times a day for nutritional support. Tube feed
formula name: Osmolite 1.5 via cyclic feeds via G-Tube 110 ml/hr via pump. Hang bag at 6:00 p.m. and take
bag down at 6:00 a.m.Observation on 11/17/25, at 9:30 a.m. Resident R60's tube feed bag was hanging on
the pole without a label, date or time it was hung and by whom as required.Interview on 11/17/25, at 12:36
p.m. Registered Nurse (RN) Employee E1 confirmed Resident R60's tube feed bag was hanging on the
pole without a label, date or time it was hung and by whom as required.Review of Resident R99's
admission record indicated she was admitted on [DATE], with the diagnoses of respiratory failure (a serious
condition that makes it difficult to breathe on your own), larynx cancer (hollow organ forming an air passage
to the lungs and holds the vocal cords), and tracheostomy (a surgical procedure to create an opening in the
neck into the windpipe to establish a direct airway for breathing).Review of Resident R99's physician order
dated 11/18/25, indicated enteral feed order two times a day for nutritional support. Tube feed formula
name: Jevity 1.5 via continuous feeding via G-Tube 55 ml/hr via pump to a total volume of
1100ml.Observation on 11/17/25, at 9:35 a.m. Resident R99's tube feed bag was hanging on the pole
without a label, date or time it was hung and by whom as required.Interview on 11/17/25, at 10:00 a.m.
Licensed Practical Nurse (LPN) Employee E3 confirmed Resident R99's tube feed bag was hanging on the
pole without a label, date or time it was hung and by whom as required.Review of the admission record
indicated Resident R117 admitted to the facility on [DATE] with the diagnoses of bipolar disease (a disorder
associated with episodes of mood swings ranging from depressive lows to manic highs), adult failure to
thrive (a syndrome of progressive physical and cognitive decline in older adults that is not a normal part of
aging), and muscle weakness. Review of Resident R117's physician order 11/14/25, indicated enteral feed
order one time a day for nutritional support. Tube feed formula name: Nutren 2.0 via cyclic feeds via G-Tube
50 ml/hr via pump for 20 hours. Down time is from 10:00 a.m. - 2:00 p.m.Observation on 11/17/25, at 9:30
a.m. Resident R117's tube feed bag was hanging on the pole without a label, date or time it was hung and
by whom as required.Interview on 11/17/25, at 9:35 a.m. LPN Employee E3 confirmed Resident R117's
tube feed bag was hanging on the pole without a label, date or time it was hung and by whom as required.
Interview on 11/17/25, at 3:00 p.m. the Director of Nursing confirmed
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395732
If continuation sheet
Page 13 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0693
Level of Harm - Minimal harm
or potential for actual harm
that the facility failed to ensure that residents with an enteral feeding tube received appropriate treatment
and services to prevent potential complications as required for three of four residents (Residents R60, R99,
and R117). 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.10(c) Resident care policies.28 Pa.
Code: 211.12(d)(1) Nursing services.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395732
If continuation sheet
Page 14 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0694
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy and documents, clinical records, and staff interviews, it was determined that the
facility failed to provide prescribed parenteral fluids (the delivery of medication or nutrition into the body via
routes that bypass the gastrointestinal tract) consistent with professional standards of practice for one of
two residents (Resident R93).Findings include: Review of the facility policy Administration Set/Tubing
Changes dated 10/7/25, indicated label tubing with date, time, and initials. Any tubing that is found not
labeled must be changed and then labeled accordingly. Review of the clinical record indicated Resident
R93admitted to the facility on [DATE]. Review of Resident R93's Minimum Data Set (MDS- a periodic
assessment of care needs) dated 10/4/25, indicated the diagnoses of anemia (the blood doesn't have
enough healthy red blood cells), high blood pressure, and peripheral vascular disease (a condition in which
narrowed blood vessels reduce blood flow to the limbs). Review of Resident R93's physician order dated
11/17/25, indicated Dextrose-Sodium Chloride Intravenous Solution 5-0.45 percent (sugar and normal
saline solution used to provide electrolytes, calories and hydration), use 50 ml/hr (milliliter/hour)
intravenously (through a vein) every shift for poor oral intake. Observation on 11/17/25, at 11:20 a.m.
Resident R93 was observed in bed with intravenous (IV) fluids being administered through a peripheral
catheter in the left wrist at 50 ml/her. The IV fluid bag failed to indicate the date, time, or who hung the bag
of fluids and the IV administration set of tubing failed to be labeled with a date as required. Interview on
11/17/25, at 11:30 a.m. Licensed Practical Nurse (LPN) Employee E3 confirmed Resident R93's IV fluid
bag failed to indicate the date, time, or who hung the bag of fluids and the IV administration set of tubing
failed to be labeled with a date as required. Interview on 11/17/25, at 2:30 p.m. the Director of Nursing
confirmed that the facility failed to provide prescribed parenteral fluids consistent with professional
standards of practice for one of two residents (Resident R93). 28 Pa. Code 201.18(b)(3) Management.28
Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(3) Nursing services.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395732
If continuation sheet
Page 15 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy, clinical records, observations and staff interviews, it was determined that the facility
failed to provide appropriate respiratory care and maintain oxygen equipment for five of eight sampled
residents (Residents R35, R74, R99, R105, and R120).Findings include: Review of the facility policy
Departmental (Respiratory Therapy) - Prevention of Infection last reviewed on 10/7/25, indicated that
considerations related to oxygen administration include change the oxygen cannula and tubing every seven
days or as needed. Keep the oxygen and tubing used as needed in a plastic bag when not in use.
Considerations related to medication nebulizers/continuous aerosol include store the circuit in a plastic bag,
marked with date and resident's name, between uses. Discard the administration set up every seven days.
Review of Resident R35's admission record indicated she was admitted on [DATE]. Review of Resident
R35's Minimum Data Set (MDS- a periodic assessment of care needs) dated 11/2/25, indicated the
diagnoses of hypertension (a condition impacting blood circulation through the heart related to poor
pressure), unspecified chronic obstructive pulmonary disease (COPD: a disease characterized by
persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs),
and heart failure (heart doesn't pump blood as well as it should). Review of Resident R35's current
physician orders indicated change oxygen tubing weekly and label with date. Change tubing weekly and
place clean tubing in plastic bag. Label and date the tubing and the bag. Wipe down nebulizer machine
once a week. Review of Resident R35's care plan on 11/18/25, at 12:00 p.m. failed to include a problem,
goal, or interventions for oxygen management. Observation on 11/17/25, at 10:00 a.m. Resident R35 was
observed in bed and using oxygen. The tubing failed to be labeled with a date as required and the nebulizer
and tubing were on the bedside stand not labeled or stored in a plastic bag as required. Interview on
11/17/25, at 12:36 p.m. Registered Nurse (RN) Employee E1 confirmed Resident R35's respiratory
equipment above was not labeled with a date and the nebulizer was not in a plastic bag as required.
Review of Resident R74's admission record indicated she was admitted on [DATE]. Review of Resident
R74's MDS dated [DATE], indicated the diagnoses of anemia (the blood doesn't have enough healthy red
blood cells), heart failure (heart doesn't pump blood as well as it should), and atrial fibrillation (irregular
heart rhythm). Review of Resident R74's current physician orders 11/18/25, at 12:05 p.m. failed to include
an order for oxygen administration. Review of Resident R74's current care plan indicated oxygen setting per
orders. Observation on 11/17/25, at 10:05 a.m. Resident R74 was observed in bed and using oxygen. The
tubing failed to be labeled with a date as required. Interview on 11/17/25, at 12:38 p.m. RN Employee E1
confirmed the respiratory equipment above was not labeled with a date and that Resident R74's orders
failed to include oxygen administration. Review of Resident R99's admission record indicated she was
admitted on [DATE], with the diagnoses of respiratory failure (a serious condition that makes it difficult to
breathe on your own), larynx cancer (hollow organ forming an air passage to the lungs and holds the vocal
cords), and tracheostomy (a surgical procedure to create an opening in the neck into the windpipe to
establish a direct airway for breathing). Review of Resident R99's current physician orders indicated
change, label, and date oxygen tubing weekly. Review of Resident R99's current care plan indicated oxygen
settings via ATM (aerosol trach mask) at FIO2 (fraction of inspired oxygen) of 28 percent. Observation on
11/17/25, at 11:19 a.m. Resident R99 was observed in bed and using oxygen through the ATM. The tubing
failed to be labeled with a date as required. Interview on 11/17/25, at 11:20 a.m. Licensed Practical Nurse
(LPN) Employee E3 confirmed Resident R99's respiratory equipment above was not labeled with a date as
required. Review of Resident R105's admission record indicated she was admitted on [DATE]. Review of
Resident
Residents Affected - Few
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395732
If continuation sheet
Page 16 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0695
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
R105's MDS dated [DATE], indicated the diagnoses of hypertension, COPD, and obsessive-compulsive
disorder (OCD- mental health condition with unwanted, recurring thoughts and repetitive behaviors).
Review of Resident R105's current physician orders indicated change oxygen tubing weekly and label with
date. Review of Resident R105's care plan on 11/18/25, at 12:00 p.m. failed to include a problem, goal, or
interventions for oxygen management. Observation on 11/17/25, at 11:20 a.m. Resident R105 was
observed in bed and using oxygen. The tubing failed to be labeled with a date as required. Interview on
11/17/25, at 11:25 a.m. LPN Employee E3 confirmed Resident R105's respiratory equipment above was
not labeled with a date as required. Review of Resident R120's admission record indicated she was
admitted on [DATE], with the diagnoses of COPD, heart failure, and end stage renal disease (kidneys
cease to function on a permanent basis leading to the need for a regular course of long-term dialysis or a
kidney transplant to maintain life). Review of Resident R120's current physician orders indicated change
oxygen tubing weekly and label with date. Review of Resident R120's baseline care plan indicated oxygen
use. Observation on 11/17/25, at 11:25 a.m. Resident R120 was observed in bed and using oxygen. The
tubing failed to be labeled with a date as required. Interview on 11/17/25, at 11:30 a.m. LPN Employee E3
confirmed Resident R120's respiratory equipment above was not labeled with a date as required. Interview
on 11/17/25, at 2:30 p.m. the Director of Nursing confirmed that the facility failed to provide appropriate
respiratory care and maintain oxygen equipment for five of eight sampled residents (Residents R35, R74,
R99, R105, and R120). 28 Pa. Code 211.10(c)(d) Resident Care Policies.28 Pa. Code 211.12(d)(1)(3)(5)
Nursing services.
Event ID:
Facility ID:
395732
If continuation sheet
Page 17 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
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, facility policy and staff interview it was determined the facility failed to
provide consistent and complete communication with the dialysis center for two of three residents (Resident
R6, and R24) and failed to have a physician order or care plan for location of dialysis treatment center for
one of three residents (Resident R120).Findings include: Review of the facility policy End-Stage Renal
Disease, Care of a Resident with dated 10/7/25, indicated residents with end-stage renal disease (ESRD)
will be cared for according to currently recognized standards of care. The agreements between the facility
and the ESRD facility will include how information will be exchanged between the facilities; and the
resident's care plan will reflect the resident's needs related to ESRD and dialysis (a treatment that removes
excess water, waste, and toxins from the blood when the kidneys are no longer functioning properly) care.
The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care.
Review of the admission record indicated Resident R6 was admitted to the facility on [DATE]. Review of
Resident R6's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 9/17/25,
indicated diagnoses of end stage renal disease (kidneys cease to function on a permanent basis leading to
the need for a regular course of long-term dialysis or a kidney transplant to maintain life), hypertension
(high blood pressure), and anxiety disorder. Review of Resident R6's physician orders dated 9/10/25,
indicated dialysis: at Fresenius Kidney Care on Tuesday, Thursday, and Saturday. Chair time 11:45 a.m.
Review of Resident R6's current care plan indicated dialysis: at Fresenius Kidney Care on Tuesday,
Thursday, and Saturday. Chair time 11:45 a.m. Review of Resident R6's dialysis communication forms
10/1/25 through 11/18/25 indicated the following:10/4, 10/11, 10/21, 10/23, 10/25, and 11/18 dialysis
communication forms had incomplete clinical documentation. 10/14, 10/18, 10/28, 11/1, 11/4, 11/8, 11/11,
11/13, and 11/15 dialysis communications forms were not found on the nursing unit in the Resident R6's
dialysis binder.Three dialysis forms are undated and have incomplete clinical data. Review of the admission
record indicated Resident R24 was admitted to the facility on [DATE]. Review of Resident R24's Minimum
Data Set (MDS - periodic assessment of resident care needs) dated 9/3/25, indicated diagnoses of end
stage renal disease (kidneys cease to function on a permanent basis leading to the need for a regular
course of long-term dialysis or a kidney transplant to maintain life) , hypertension (high blood pressure),
and atrial fibrillation (irregular heartbeat). Review of Resident R24's physician orders dated 9/23/25,
indicated dialysis: at Davita Northside on Monday, Wednesday, and Friday. Chair time 6:00 a.m. Review of
Resident R24's current care plan indicated dialysis: at Davita Northside on Monday, Wednesday, and
Friday. Chair time 6:00 a.m. Review of Resident R24's dialysis communication forms 10/1/25 through
11/18/25 indicated the following:10/3, 10/6, 10/10, 10/15, 10/17, 10/20, 10/22, 10/27, 10/29, 11/3, and 11/5
dialysis communication forms had incomplete clinical documentation. 10/1, 10/8, 10/13, 10/31, 11/7, 11/10,
11/12, 11/14, and 11/17 dialysis communications forms were not found on the nursing unit in the Resident
R24's dialysis binder. Interview on 11/19/25, at 10:25 a.m. Registered Nurse (RN) Employee E13 confirmed
the facility failed to provide consistent and complete communication with the dialysis center for Residents
R6 and R24's dialysis center as required. Review of Resident R120's admission record indicated she was
admitted on [DATE], with the diagnoses of COPD, heart failure, and end stage renal disease (kidneys
cease to function on a permanent basis leading to the need for a regular course of long-term dialysis or a
kidney transplant to maintain life). Review of Resident R120's MDS dated [DATE], indicated the diagnoses
of hypertension, COPD, and obsessive compulsive disorder (OCD- mental health condition with unwanted,
recurring thoughts and repetitive behaviors).
Residents Affected - Some
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395732
If continuation sheet
Page 18 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0698
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Review of Resident R120's current physician orders failed to indicate a location name and time of resident's
dialysis center as required. Review of Resident R120's baseline care plan failed to indicate a location name
and time of resident's dialysis center as required. Interview on 11/19/25, at 11:30 a.m. Registered Nurse
(RN) Employee E7 confirmed the facility failed to identify the location name and time of Resident R120's
dialysis center as required. Interview on 11/20/25, at 3:00 p.m. the Director of Nursing confirmed the facility
failed to provide consistent and complete communication with the dialysis center for two of three residents
(Resident R6, and R24) and failed to have a physician order or care plan for location of dialysis treatment
center for one of three residents (Resident R120). 28 Pa. Code 201. 18(b)(1) Management 28 Pa
code:211.10(c)(d) Resident care policies 28 Pa. Code 211.11(d) Resident care plan. 28 Pa
Code:211.12(a)(c)(d)(1)(2)(5) Nursing services
Event ID:
Facility ID:
395732
If continuation sheet
Page 19 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, clinical record review, review of select manufacture's guidelines, and staff interview,
it was determined that the facility failed to ensure a medication error rate below five percent (Resident
R19).Findings include: The facility's medication error rate was 8% (percent) based on 25 medication
opportunities with two medication errors. During a medication observation on 11/18/25, at 8:11 a.m.
Licensed Practical Nurse (LPN) Employee E6 was preparing to administer Resident R19's morning dose of
Lispro insulin. LPN Employee E6 verified the correct insulin and the correct dose; however, was not aware
and did not prime the pen prior to drawing up the dose of 76 units.Further observation of LPN Employee
E6's medication administration to Resident R19 failed to receive 17 gram Miralax (laxative medication used
to treat occasional constipation or irregular bowel movements). Nurse had mixed the Miralax in with the
liquid protein and water which resident refused. Nurse disposed of the mixture and did not repour the
Miralax as ordered.Interview with the Director of Nursing on 11/18/25, at 3:00 p.m. confirmed the facility
failed to ensure a medication error rate below five percent (Resident R19). 28 Pa. Code 211.10(a) Resident
care policies28 Pa. Code 211.12(d)(1)(5) Nursing services
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395732
If continuation sheet
Page 20 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, review of facility policy, manufacturer recommendations, resident interviews, clinical records,
and staff interview, it was determined that the facility failed to make certain that residents are free of
significant medication errors for one of three residents observed (Resident R19).
Residents Affected - Few
Findings include:
Review of the facility policy Adverse Consequences and Medication Errors dated 10/7/25, indicated a
medication error is defined as the preparation or administration of drugs or biological which is not in
accordance with physician's orders, manufacturer's specifications, or accepted professional standards and
principles of the professional providing services.
Review of the manufacturer's guideline for Insulin Lispro KwikPen dated July 2023, indicated to prime the
pen, select a dose of two units, hold the pen with the needle pointing upwards, gently tap the reservoir to
remove air bubbles, press the injection button all the way in and check if insulin comes out of the needle tip.
Then select the insulin dose ordered.
Review of the admission record indicated Resident R19 admitted to the facility on [DATE].
Review of Resident R19's Minimum Data Set (MDS - a periodic assessment of care needs dated 11/5/25,
indicated the diagnoses of Charcot joint (the bones, joints, and soft tissues of the foot and ankle are
destroyed due to nerve damage most commonly caused by diabetes-related peripheral neuropathy),
diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for
energy), and right below the knee amputation (surgical removal of a limb for medical conditions).
Review of Resident R19's physician order dated 10/29/25, indicated Insulin Lispro Injection Solution 100
UNIT/ML (milliliter) inject 76 units subcutaneously (in the fat layer) one time a day for breakfast. Meal has to
be sitting in front of resident.
During a medication observation on 11/18/25, at 8:11 a.m. Licensed Practical Nurse (LPN) Employee E6
was preparing to administer Resident R19's morning dose of Lispro insulin. LPN Employee E6 verified the
correct insulin and the correct dose; however, was not aware and did not prime the pen prior to drawing up
the dose of 76 units.
Interview with LPN Employee E6 on 11/18/25, at 8:12 a.m. indicated the staff member was not aware of
manufacturer's guidelines to prime the pen before each injection.
Interview on 11/18/25, at 1:00 p.m. the Director of Nursing confirmed that facility failed to administer the
correct dose of insulin by failing to prime the insulin pen needle for Resident R19 as required.
Review of the admission record indicated Resident R119 was admitted to the facility on [DATE].
Review of Resident R119's MDS dated [DATE], indicated diagnosis of leukemia, unspecified not having
reached remission ( a cancer in the blood , characterized by the rapid growth of abnormal blood cells. This
uncontrolled growth takes place in your bone marrow) , and antineoplastic chemotherapy induced
pancytopenia (having low levels of red blood cells, white blood cells, and platelets).
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395732
If continuation sheet
Page 21 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0760
Review of physician orders dated 9/10/25, indicated:
Level of Harm - Minimal harm
or potential for actual harm
Isavuconazonium Sulfate Oral Capsule 186 MG
(Isavuconazonium Sulfate) Give 2 capsule by mouth
Residents Affected - Few
one time a day for fungal infection swallow whole
Letermovir Oral Tablet 480 MG (Letermovir) Give 1
tablet by mouth one time a day for antiviral Should not
be crushed
levofloxacin Oral Tablet 750 MG (Levofloxacin)
Give 1 tablet via PEG-Tube one time a day for UTI
until 09/14/2025 21:00
Magnesium Oxide -Mg Supplement Oral Tablet 400
(240 Mg) MG (Magnesium Oxide (Mg Supplement))
Give 1 tablet by mouth two times a day for
Supplement
Olanzapine Tablet 5 MG Give 1 tablet via PEG-Tube
at bedtime for psychotic disorder
Review of the MAR (medication administration record a clinical document used to track residents'
medications given) dated 9/16/25, indicated that lsavuconazonium sulfate oral capsule, letermovir oral
tablet, levofloxacin oral tablet, magnesium oxide, and olanzapine had a code 16.
Review of the MAR for code 16 indicated: outside of parameters for admin/held md orders.
Review of clinical record failed to include physician orders for hold of medications.
During an interview on 11/21/25, at 9:40 a.m. DON (Director of Nursing) confirmed that the medication was
not given as ordered - staff failed to realize Resident R119 was out to an appointment and medication need
to be given prior to leaving facility.
During an interview on 11/21/25, at 9:42 a.m. DON was informed that the facility failed to provide
medications as ordered resulting in a significant medication error.
28 Pa Code: 211.10 (d) Resident care policies.28 Pa. Code 211.12 (c)(1)(3) Nursing Services.28 Pa Code:
201.18 (b)(1)(3) Management.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395732
If continuation sheet
Page 22 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policies, observations, and staff interviews, it was determined that the facility failed to store
medications and biologicals properly for three of three medication carts (Second Floor East and South
Medication carts and Third Floor South Medication cart) and two of two medication rooms (Second and
Third Floor).Findings include: Review of the facility policy Storage of Medications last reviewed [DATE]/25,
indicated that medications and biologicals are stored safely, securely, and properly. Medication storage
areas are kept clean, well lit, and free of clutter. Observation on [DATE], at 8:02 a.m. of the Second Floor
East Medication cart revealed pre-poured medications for the following residents' morning medication
administration - Resident R25, Resident R42, Resident R32, and Resident R108. Further investigation of
the Second Floor East Medication cart revealed the following medications opened and not labeled with a
date as required:-Ipratropium solution (assists in making breathing easier)-albuterol nebulizer solution
(assists in making breathing easier)-budesonide solution (assists in making breathing easier)-Lantus insulin
pen (prefilled pen to inject long-acting insulin under the skin). Interview on [DATE], at 8:05 a.m. Registered
Nurse (RN) Employee E5 confirmed the medications were pre-poured and not administered at the time of
dispensing as required and that the above identified medications were not labeled with a date when opened
as required. Observation on [DATE], at 9:02 a.m. of the Second Floor South Medication cart revealed the
following medications opened and not labeled with a date as required:-Trelegy inhaler (assists in making
breathing easier)-Ipratropium solution (assists in making breathing easier) Interview on [DATE], at 9:05 a.m.
RN Employee E4 confirmed that the above identified medications were not labeled with a date when
opened as required. Observation on [DATE], at 9:30 a.m. of the Third Floor South Medication cart revealed
the following medications opened and not labeled with a date as required:-liraglutide pen (used to improve
blood sugar control)-Lantus insulin pen, three different vials-Novolog insulin pen (prefilled pen to inject
rapid-acting insulin under the skin) -Humalog insulin pen (Lispro - a short acting, manmade version of
human insulin) three different vials-Breolipta inhaler (assists in making breathing easier)-Fluticasone inhaler
(assists in making breathing easier)-Albuterol inhaler two different vials. Interview on [DATE], at 9:33 a.m.
RN Employee E7 confirmed that the above identified medications were not labeled with a date when
opened as required. Observation on [DATE], at 10:57 a.m. of the Third Floor Medication Room revealed a
package of butterfly needles (small needles used for difficult intravenous access) that had expired on
[DATE]. Interview on [DATE], at 11:00 a.m. RN Employee E9 confirmed the needles were expired and
should have been disposed of. Observation on [DATE], at 11:11 a.m. of the Second Floor Medication Room
revealed a frozen dinner entree in the freezer of the medication refrigerator. Interview on [DATE], at 11:12
a.m. RN Employee E9 confirmed the frozen dinner entree in the freezer of the medication refrigerator was
not permitted to be stored in the medication freezer. Interview on [DATE], at 1:00 p.m. the Director of
Nursing confirmed the facility failed to store medications and biologicals properly for three of three
medication carts (Second Floor East and South Medication carts and Third Floor South Medication cart)
and two of two medication rooms (Second and Third Floor). 28 Pa. Code: 211.9(a)(1)(k) Pharmacy
services.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.
Event ID:
Facility ID:
395732
If continuation sheet
Page 23 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
Based on observation, and staff interview it was determined that the facility failed to properly approve the
current menu cycle with the registered dietician as required for two of two nursing units (second and third
floor nursing units).Findings include: During an observation on 11/17/25 and 11/18/25, on the Second and
Third Nursing Floor unit's menus were posted (3 different weeks with a print date of 10/25) that failed to
include a Registered Dietician acknowledgement that the weeks of the diet menu had been reviewed and
approved. During an interview on 11/18/25, at the NHA (Nursing Home Administrator) was informed that
the facility failed to properly approve the current menu cycle with the registered dietician. 28 Pa. Code
211.6(a)(b) Dietary services.
Event ID:
Facility ID:
395732
If continuation sheet
Page 24 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0806
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Ensure each resident receives and the facility provides food that accommodates resident allergies,
intolerances, and preferences, as well as appealing options.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, resident and staff interviews it was determined that the facility failed to provide residents with
food products based on their preferences for 18 of 27 residents (Resident R10, R4, R43, R46, R70, R108,
R111, R700, R701, R702, R703, R704, R705, R706, R707, R708, R709, and R710).Based on
observations, resident and staff interviews it was determined that the facility failed to provide residents with
food products based on their preferences for eighteen of twenty-seven residents (Resident R10, R4, R43,
R46, R70, R108, R111, R700, R701, R702, R703, R704, R705, R706, R707, R708, R709, and R710).
Review of the facility policy Resident Food Preferences dated 10/7/25, with a previous review date of
9/25/24, indicated all residents' food preferences will be obtained within 72 hours of admission and will be
reviewed as necessary to ensure resident acceptance and satisfaction. The Dining Services Manager, or
designee, will interview residents and/or family members within 72 hours of admission to the facility to
obtain a list of food preferences' including likes and dislikes, choice of beverages, and choice of breakfast
cereals. Food preferences will be entered into the electronic meal tracking system. During an interview on
11/17/25 at 9:29 a.m. with Resident R10's family, shared a concern related to ongoing meal inaccuracy.
Observation of Resident R10's breakfast tray and tray ticket on 11/17/25, at 9:29 a.m. revealed resident is
on a nectar thick puree diet. The meal ticket indicated the resident is to receive two yogurts, nectar thick
orange juice, nectar thick milk, puree hot cereal, and puree French toast, no yogurt was provided on the
tray. During an interview on11/17/25 at 9:39 a.m., with Registered Nurse (RN) Employee E9 confirmed the
tray had no yogurt and that it should have been provided. Review of the admission record indicated
Resident R10 was admitted to the facility on [DATE]. Review of Resident R10's Minimum Data Set (MDS - a
periodic assessment of care needs) dated 9/25/25, indicated the diagnoses of parkinsonism (slowed
movements, stiffness, and tremors), cerebrovascular accident (stroke sudden loss of blood flow to part of
the brain), and takotsubo syndrome (weakening of the heart's main pumping chamber). During an interview
on 11/17/25 at 9:40 a.m. with Resident R43 shared a concern related to ongoing meal inaccuracy. Resident
stated he did not eat any of his breakfast this morning as he didn't really want French toast and they didn't
send the eggs with the tray. The resident stated this happens all the time. Observation of Resident R43's
breakfast tray and tray ticket on 11/17/25, at 9:40 a.m. revealed resident is on a regular diet. The meal ticket
indicated the resident is to receive milk, orange juice, hot cereal, scrambled eggs, French toast and a hot
beverage, no eggs were provided on the tray. During an interview on 11/17/25 at 9:45 a.m., with Registered
Nurse (RN) Employee E4 confirmed that no food on the tray had been touched or eaten by the resident, the
tray had no eggs, and eggs should have been provided. Review of the admission record indicated Resident
R43 was admitted to the facility on [DATE]. Review of Resident R43's Minimum Data Set (MDS - a periodic
assessment of care needs) dated 10/24/25, indicated the diagnoses of cerebral ischemia (insufficient blood
flow to the brain), high blood pressure, and cerebrovascular accident (stroke sudden loss of blood flow to
part of the brain). During an interview on 11/17/25 at 12:24 p.m. with Resident R70 shared a concern
related to ongoing meal inaccuracy. Resident stated he did not get his ginger ale on his lunch tray, and they
don't have any soda on the nursing unit, it's like they forget something on my tray every day. Observation of
Resident R70's lunch tray and tray ticket on 11/17/25, at 12:24 p.m. revealed resident is on a regular diet.
The meal ticket indicated that the resident is to receive a dinner roll, tropical fruit, milk, ginger ale,
beefaroni, carrots, and a hot beverage, no ginger ale was provided on the tray. During an interview on
11/17/25 at 12:34 p.m., with certified nursing
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395732
If continuation sheet
Page 25 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0806
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
assistant (CNA) Employee E12 confirmed there was no ginger ale on the tray, and it should have been
provided. Review of the admission record indicated Resident R70 was admitted to the facility on [DATE].
Review of Resident R70's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/30/25,
indicated the diagnoses of atrial fibrillation (irregular heart rhythm), high blood pressure, and depression.
During an interview on 11/17/25, at 12:36 p.m., Resident R108 asked the Survey Agency (SA) to take the
lunch tray away. When asked what the concern was, Resident R108 indicated they cannot have tomato
sauce. Observation of Resident R108's lunch tray on 11/17/25, at 12:36 p.m. revealed macaroni noodles,
beef, and tomato sauce (beefaroni). The tray ticket clearly indicated pasta with NO Tomato Sauce. During
an interview with Registered Nurse (RN) Employee E1 confirmed the tray had tomato sauce and should not
have. Review of the admission record indicated Resident R108 was admitted to the facility on [DATE].
Review of Resident R108's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/2/25,
indicated the diagnoses of atrial fibrillation (irregular heart rhythm), high blood pressure, and
gastroesophageal reflux disease (chronic disorder where stomach acid flows back into the esophagus).
During an interview of 11/17/25, at 12:36 p.m. Dietary Employee E2 confirmed Resident R108's tray was
not correct and that the facility failed to provide residents with food products based on their preferences.
During a resident group interview on 11/17/25, at approximately 1:30 p.m., when asked if they felt the
facility honored their food preference, consensus from the group was no. Residents verbalized frustration
with ongoing inaccuracy with their meal selections. Residents stated it doesn't matter if it's breakfast lunch
or dinner, sometimes it's not what you selected, it's missing one item maybe more. Resident R701 stated
they called the ombudsman due to the issues she is having with the meals, and nothing has been resolved.
Resident R703 stated the meals are an everyday problem for us. Resident R708 broke out into laughter
and said, I don't think they get one meal right in a day. During a resident interview on 11/18/25, at 8:47
a.m., Resident R4 stated that food is always cold, and we do not get everything on our trays we request.
The kitchen uses foam every other day as the dish machine is always broken. They have sent a breakfast
sausage as a hamburger do they think we can't tell? During an interview on 11/18/25, at 8:56 a.m.,
Resident R46 was lying in bed. The resident's spouse stated that the facility fails to have enough foods that
are Kosher for his needed diet as he requires a soft diet. The meals are always cold, and the kitchen uses
foam a lot. The kitchen never sends yogurt as requested. During an interview on 11/18/25, at 8:25 a.m.,
Resident R111 stated that the food was always cold, and the facility sends foam plates up every other day.
During an interview on 11/19/25, at 1:35 p.m., Regional Nursing Home Administrator Employee E10
confirmed that the facility failed to provide residents food products based on their preferences. During an
interview on 11/18/25 at 10:00 a.m. the Director of Nursing confirmed that the facility failed to provide
residents with food products based on their preferences, for eighteen of twenty-seven residents (Resident
R10, R4, R43, R46, R70, R108, R111, R700, R701, R702, R703, R704, R705, R706, R707, R708, R709,
and R710). Pa Code: 201.14(a) Responsibility of licensee.
Event ID:
Facility ID:
395732
If continuation sheet
Page 26 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0810
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Level of Harm - Minimal harm
or potential for actual harm
Based on facility policy, observation and resident and staff interview it was determined that the facility failed
to provide special eating equipment and utensils for residents who need them and appropriate assistance
to ensure that the resident can use the assistive devices when consuming meals and snacks for one of two
residents (Resident R111).During an interview on 11/18/25, at 8:25 a.m., Resident R111 was attempting to
eat her breakfast out of a foam container. Resident R111 stated that she is supposed to have a scoop plate
so she can feed herself, but the dish machine has been broken, and the facility has been using
foam.Review of Resident R111's current care plan indicated the use of a scoop dish for all meals. During an
interview on 11/21/25, at 10:24 a.m., Therapy Manager Employee E15 stated that she cannot provide
documentation for assessment for need of scoop plate as that was before WE Care took over however, the
resident is still supposed to be getting it. She confirmed that the facility failed to provide proper special
eating equipment for Resident R111.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395732
If continuation sheet
Page 27 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
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 a review of facility policy, observations and staff interview, it was determined that the facility failed
to properly label and date food products in the walk-in cooler and freezer in the designated main kitchen.
Findings include: A review of the facility Food Storage policy dated 10/7/25, indicated food storage areas
shall be maintained in clean, safe, and sanitary manner. During an observation of the main designated
kitchen on 11/18/25 at 10:30 a.m. the following was observed:-crate of iced tea on the floor of the walk-in
coolerWalkin Freezer-2 bags of rolls, out of original package, no label or date-Bacon, not covered, no label
or date-egg patties,1 bag, no label or date-french fries, 2 bags, no label or date -Bottle of disinfectant stored
on the shelf with noodles and open container of bread crumbs During an interview on 11/18/25 at 11:15
a.m., Dietary Manager Employee E8 confirmed that the facility failed to properly label and date food
products which created the potential for food borne illness. 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:
395732
If continuation sheet
Page 28 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0814
Dispose of garbage and refuse properly.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation and staff interview it was determined that the facility failed to properly contain and
dispose of garbage in outside dumpsters to prevent the potential for rodent and insect infestation. Findings
include: During an observation and interview of the facility's outdoor trash compactor and dumpster on
11/17/25, at 10:15 a.m. with Dietary Manager (DM) E8 confirmed that there were trash and debris
collecting in the disposal area, the dumpster lid was open and that the facility failed to properly contain and
dispose of garbage in outside dumpster area to prevent potential rodent and insect infestation. 28 Pa. Code
201.18(b)(3) Management.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395732
If continuation sheet
Page 29 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0865
Have a plan that describes the process for conducting QAPI and QAA activities.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of facility documentation, cited deficiencies from previous surveys, review of plan of
correction documentation, and staff interview, it was determined that the facility's Quality Assurance and
Performance Improvement (QAPI) program failed to correct previously cited deficiencies. This has the
potential to affect 105 of 105 residents.Finding include:Review of the facility policy Quality Assurance and
Performance Improvement (QAPI) Program dated 10/7/25, indicated objectives of the QAPI program
include providing a means to measure current and potential indicators for outcomes of care and quality of
life; establish and implement performance improvement projects to correct identified negative or
problematic indicators; reinforce and build upon effective systems and processes related to the delivery of
quality care and services; and establish systems through which to monitor and evaluate corrective
actions.Review of the facility's deficiencies and plan of corrections for the State Survey and Certification
(Department of Health) survey ending 12/6/24, revealed the facility developed a plan of correction that
included quality assurance systems to ensure that the facility-maintained compliance with cited nursing
home regulations.Review of the plan of correction for survey ending 12/6/24, revealed the following:- DON,
or designee, will in-service R.N.'s and L.P.N.'s on the facility policy and procedure for Self-Administration of
Medications to ensure that all nurses understand the requirements for resident's to be able to administer
their own medications, as well as be educated on the Self-Administration Evaluation Form. - NHA, or
designee, will in-service all facility physicians on the facility policy and procedure for Self-Administration of
Medications to ensure they have a thorough understanding of the requirements for the facility to
self-administer medications.- DON, or designee, will audit all resident orders to ensure any resident that
has an order to self-administer medications meets the facility policy and procedure requirements for
self-administering medications, any residents identified as self-administering will have a self-administration
evaluation completed to determine eligibility.- DON, or designee, will monitor five resident(s) 2 x a week for
2 weeks, 1x a week for 2 weeks and monthly thereafter to ensure that residents with self-administration
orders are meeting the facilities policy and procedure requirements. - Education provided, audits and
monitoring will be reported to and reviewed by the QAPI team at the next schedule meeting. The results of
the current survey, ending 11/21/25, identified a repeated deficiency related to Self-Administration of
medications for one resident (Resident R42).Review of the plan of correction for survey ending 12/6/24,
revealed the following:- DON, or designee, will in-service all facility R.N.'s and L.P.N.'s on the facility policy
and procedure for Enteral Tube Feeding via Continuous Pump and Medication and Treatment Orders to
ensure compliance with orders for all residents with tube feeds. - DON audited all residents with tube feeds
during survey to ensure that their tube feed was administered per physician order and policy. - DON, or
designee, will monitor all residents with a tube feed via continuous pump 2 x per week for 2 weeks, then
once per week for 2 weeks and monthly thereafter to ensure all tube feeds are hung per physician order
and policy. - Education provided, audits and monitoring will be reported to and reviewed by the QAPI team
at the next schedule meeting. The results of the current survey, ending 11/21/25, identified a repeated
deficiency related to enteral tube feeding via continuous pump not being labeled properly for three
residents (Resident R60, R99, and R117).Review of the plan of correction for survey ending 12/6/24,
revealed the following:- DON, or designee, will in-service all direct care staff on the facility policy and
procedure for Administering Nebulizer through a Small Volume (Handheld) Nebulizer, Oxygen
Administration and Respiratory Therapy-Prevention of Infections to ensure compliance with all policies and
procedures surrounding oxygen/nebulizer administration. - All residents with oxygen and nebulizers were
audited during survey and
Residents Affected - Some
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395732
If continuation sheet
Page 30 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0865
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
identified issues were corrected immediately.- DON, or designee, will monitor residents three (at random)
residents with oxygen/nebulizer 2 x per week for 2 weeks, once per week for 2 weeks and monthly
thereafter to ensure compliance with nebulizer and oxygen administration policies. - Education provided,
audits and monitoring will be reported to and reviewed by the QAPI team at the next schedule meeting. The
results of the current survey, ending 11/21/25, identified a repeated deficiency related to nebulizers and
respiratory equipment not being labeled with date changed for five residents (Resident R35, R74, R99,
R105, and R120).Review of the plan of correction for survey ending 12/6/24, revealed the following:- DON,
or designee, will in-service all facility R.N.'s and L.P.N's on the facility policy and procedure for End Stage
Renal Disease, Care of a Resident With to ensure compliance with dialysis communication and
care-planning.- DON, or designee, will audit all residents currently receiving Dialysis services to ensure that
the required information has been care planned for each resident. - DON, or designee, will in-service facility
dialysis partners on the requirements of Dialysis Communication per our facility policy and procedure. DON, or designee, will monitor dialysis residents 2 x per week for 2 weeks, once per week for 2 weeks then
monthly thereafter to ensure compliance with dialysis communication and care planning. - Education
provided, audits and monitoring will be reported to and reviewed by the QAPI team at the next schedule
meeting. The results of the current survey, ending 11/21/25, identified a repeated deficiency related to
dialysis care physician orders and care plan along with management and communication to dialysis center
for three residents (Residents R6, and R24, R120).Review of the plan of correction for survey ending
12/6/24, revealed the following:- NHA, or designee, will in-service facility DON, ADON and physicians on
the facility policy and procedure for Medication Regimen Review to ensure compliance from physicians with
the monthly recommendations. - DON, or designee, will audit pharmacy recommendations for the 30 days
to ensure compliance with the completion. - DON, or designee, will audit 3 residents (at random) with
pharmacy recommendations twice per week for 2 weeks, then once weekly for 2 weeks and monthly
thereafter to ensure completion with the pharmacist recommendations.- Education provided, audits and
monitoring will be reported to and reviewed by the QAPI team at the next schedule meeting. The results of
the current survey, ending 11/21/25, identified a repeated deficiency related to Medication Regimen Review
to ensure compliance from physicians with the monthly recommendations for one resident (Resident
R1).Review of the plan of correction for survey ending 12/6/24, revealed the following:- DON, or designee,
will in-service all facility R.N.'s and L.P.N's on the facility policy and procedure for Administering
Medications to ensure compliance and accuracy with the medication pass. - DON audited resident who did
not receive their over the counter medications timely during the med pass of survey to ensure that they did
not have any adverse reactions and they did not. - DON, or designee, will monitor six med passes per week
on varying shifts for 2 weeks, then 4 med passes per week on varying shifts for 2 weeks and monthly after
that to ensure compliance and accuracy with med passes. - Education provided, audits and monitoring will
be reported to and reviewed by the QAPI team at the next schedule meeting. The results of the current
survey, ending 11/21/25, identified a repeated deficiency related to Medication Error Rate greater than 5%.
Error rate for current survey was 8% affecting one resident (Resident R19).Review of the plan of correction
for survey ending 12/6/24, revealed the following:-DON, or designee, will in-service all facility RN's and
LPN's on the facility policy and procedure for Medication Storage and Insulin Storage to ensure compliance
with the storage and distribution of all medications. -DON addressed self-administration with resident
identified as having senna in his top drawer, resident will no longer self-administer until MD evaluates for
the possibility of self-administration. -DON, or designee, will monitor facility med carts 2 x per week for 2
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395732
If continuation sheet
Page 31 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0865
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
weeks, then weekly x 2 weeks and monthly thereafter to ensure compliance with the storage of all
medications.The results of the current survey, ending 11/21/25, identified a repeated deficiency related
medication storage and insulin storage for three of three medication carts (Second Floor East and South
Medication carts and Third Floor South Medication cart) and two of two medication rooms (Second and
Third Floor).Review of the plan of correction for survey ending 12/6/24, revealed the following:-NHA, or
designee, will in-service all dietary and direct care staff on the facility policy and procedure for assistance
with meals. -NHA, or designee, will audit all existing residents tray tickets versus Point Click Care order to
ensure accuracy. -NHA, or designee, will monitor 3 residents (at random) twice weekly for 2 weeks then
once weekly for 2 weeks and monthly thereafter to ensure compliance with assistance with meals and the
proper tools. -all results of educations, audit and monitoring will be reported to QAPI at the next scheduled
meeting.The results of the current survey, ending 11/21/25, identified a repeated deficiency related to
assistance with meals and special equipment for one resident (Resident R111).Review of the plan of
correction for survey ending 12/6/24, revealed the following:NHA, or designee, will in-service dietary staff
on the facility policy and procedure for Preventative Maintenance and Weekly Cleaning and Preventing
Foodborne Illness-Employee Hygiene and Sanitary Practices to ensure that all dietary staff are in
compliance with regulatory practices. The areas identified during survey have been addressed, cleaned and
sanitized. NHA, or designee, will audit the kitchen to ensure all areas of concern with cleanliness are
addressed immediately. NHA, or designee, will monitor the kitchen 2x per week for 2 weeks, then once per
week for 2 weeks and monthly thereafter to ensure the kitchen maintains proper sanitary conditions. All
results of education, audit and monitor will be presented to the QAPI committee at the next scheduled
meeting.The results of the current survey, ending 11/21/25, identified a repeated deficiency related to
dietary sanitation and food storage, as well as refrigerator temperature logs.Review of the plan of correction
for survey ending 12/6/24, revealed the following:-NHA, or designee, will in-service all staff on the facility
policy and procedure for Enhanced Barrier Precautions and Handwashing to ensure proper infection control
practices are being followed. -DON, or designee, will in-service all facility RN's and LPN's on the policy and
procedure for Insulin administration to ensure proper infection control processes are followed during the
administration of insulin. -DON, or designee, will perform handwashing competency on all facility staff.
-DON, or designee, will monitor 3 residents (at random) who are in ebp 2 x a week for 2 weeks, then 1 time
a week for 2 weeks then monthly thereafter to ensure staff compliance with the enhanced barrier
precaution regulatory processes. -DON, or designee, will monitor 2 residents (at random) insulin
administration twice per week for two weeks, then once per week for two weeks and monthly thereafter to
ensure compliance with the infection control practices during insulin administration. -all results of education,
competencies, audits and monitoring will be reported to the QAPI committee at the next scheduled
meeting.The results of the current survey, ending 11/21/25, identified a repeated deficiency related to
Enhanced Barrier Precautions and hand washing for (Resident R60 and R99) with enteral feeding tubes
(G- Tube, a tube inserted in the stomach through the abdomen), failed to utilize proper handwashing and
gloving during medication administration for one of five residents observed (Resident R19).Interview on
11/21/25, at 12:00 p.m. the Director of Nursing and Nursing Home Administrator were informed that the
facility's Quality Assurance and Performance Improvement (QAPI) program failed to correct previously cited
deficiencies. This has the potential to affect 105 of 105 residents.42 CFR 483.75 (a)(2)(h)(i) QAPI
Program/Plan, Disclosure/Good Faith Attempt.28 Pa. Code 201.18(e)(1) Management.28 Pa. Code
201.18(e)(2)(3)(4) Management.
Event ID:
Facility ID:
395732
If continuation sheet
Page 32 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0868
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Level of Harm - Minimal harm
or potential for actual harm
Based on review of Quality Assurance attendance records, and staff interview, it was determined that the
facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly for three of
three quarterly meetings (Quarter one, two, three of 2025).Findings include: Review of Quality Assurance
and Performance Improvement (QAPI) sign in sheets and attendance records revealed only one QAPI
meeting held in 2025, October 16, 2025. During an interview on 11/20/25, at 8:35 a.m. The Nursing Home
Administrator confirmed the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at
least quarterly as required. 28 Pa Code: 201.18(e)(1)(2)(3)(4) Management
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395732
If continuation sheet
Page 33 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy, clinical record review, observations, and staff interviews, it was determined that the
facility failed to follow enhanced barrier precautions (EBP) for two of four residents (Resident R60 and R99)
with enteral feeding tubes (G- Tube, a tube inserted in the stomach through the abdomen), failed to utilize
proper handwashing and gloving during medication administration for one of five residents observed
(Resident R19), and failed to complete Infection Control surveillance from November 2024 through
November 2025, failed to monitor Antibiotic Stewardship for May 2025 and failed to provide vaccines for flu,
pneumonia and COVID-19 to 105 of 105 residents for the 2025 season, resulting in substandard quality of
care.Findings include:
Residents Affected - Many
Review of the facility policy Enhanced Barrier Precautions dated 10/7/25, indicated enhanced barrier
precautions (EBP) are used and expand the use of Personal Protective Equipment (PPE) to donning
(putting on) of the gown and gloves during high-contact resident care activities that provide opportunities for
transfers of multidrug-resistant organisms to staff hands and clothing. Examples of high-contact resident
care activities requiring EBP includes device care or use (central lines, urinary catheter, supra-pubic
catheter, feeding tube or tracheostomy. Signs are posted in the door or wall outside the resident room
indicating the type of precautions and PPE required. PPE is available outside of the resident rooms.
Review of the facility policy Administering Medications dated 10/7/25, indicated staff follow established
facility infection control procedures (handwashing, antiseptic technique, gloves, etc.) for the administration
of medications as applicable.
Review of the admission record indicated Resident R60 admitted to the facility on [DATE].
Review of Resident R60's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/30/25,
indicated diagnoses of malnutrition (body doesn't receive enough calories or the right balance of nutrients
to stay healthy), schizophrenia (characterized by thoughts or experiences that seem out of touch with
reality, and anemia (the blood doesn't have enough healthy red blood cells).
Review of Resident R60's physician order 9/25/25, indicated EBP for G-tube.
Observation on 11/17/25, at 9:30 a.m. Resident R60's door had no signage for EBP or PPE outside the
room. Staff were observed going in and out of the room without donning gowns.
Interview on 11/18/25, at 1:26 p.m. Registered Nurse (RN) Employee E4 confirmed Resident R60's door
had no signage for EBP or PPE outside the room as required.
Review of Resident R99's admission record indicated she was admitted on [DATE], with the diagnoses of
respiratory failure (a serious condition that makes it difficult to breathe on your own), larynx cancer (hollow
organ forming an air passage to the lungs and holds the vocal cords), and tracheostomy (a surgical
procedure to create an opening in the neck into the windpipe to establish a direct airway for breathing).
Review of Resident R99's physician order 11/18/25, indicated EBP for wounds and feeding tube and failed
to include the status of a tracheostomy requiring EBP as required.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395732
If continuation sheet
Page 34 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Observation on 11/17/25, at 9:35 a.m. Resident R99's door had no signage for EBP or PPE outside the
room. Staff were observed going in and out of the room without donning gowns.
Interview with Resident R99 on 11/17/25, at 9:35 a.m. when asked if staff wear gowns while they care for
the resident, the resident nodded the head no.
Residents Affected - Many
Interview on 11/18/25, at 1:26 p.m. Registered Nurse (RN) Employee E4 confirmed Resident R99's door
had no signage for EBP or PPE outside the room as required.
Observation on 11/18/25, at 9:15 a.m. of a medication pass Licensed Practical Nurse (LPN) Employee E6
failed to utilize proper handwashing and gloving techniques and popped several medications into the bare
hand and then placed into a medication cup.
Interview with the Director of Nursing on 11/18/25, at 3:00 p.m. confirmed the facility failed to follow
enhanced barrier precautions (EBP) for two of four residents (Resident R60 and R99) with enteral feeding
tubes (G- Tube, a tube inserted in the stomach through the abdomen), failed to utilize proper handwashing
and gloving during medication administration for one of five residents observed (Resident R19).
Resident R116 was admitted to the facility on [DATE].
Review of Resident R116's admission record indicated a diagnosis of fracture of right lower leg and COVID
(infectious disease caused by the SARS CoV-2 virus).
During an interview on 11/17/25, at 9:56 a.m. Resident R116 shared that she didn't realize she had COVID
and she thought that was part of the reason she feels (due to feeling weak).
During an observation on 11/17/25, at 10:00 a.m. no signage was noted on Resident R116 to identify what
PPE equipment should be used, the door was open, and the PPE on the door failed to include all required
items.
During an interview on 11/17/25, at 10:11 a.m. with Unit Manager RN Employee E9 stated that the facility
did not have any active cases of COVID. Unit Manager RN Employee E9 confirmed that the PPE on the
door did not contain all required equipment.
Review of Resident R116 admission paperwork indicated that Resident R116 was diagnosed with COVID
in the hospital and it was indicated on the hospital paperwork.
During an interview on 11/20/25, at 9:45 a.m. Director of Nursing was informed that the facility failed to
identify and implement infection control practices for Resident R116.
During review of the Infection Control Practices surveillance information, Antibiotic Stewardship
documentation and 2025 vaccine documentation did not include monitoring of and surveillance that
identified trending of infections from November 2024, through November 2025, monitoring of antibiotics for
May 2025, or the offering. provision of vaccines for the 2025 flu, pneumonia or COVID-19, season.
During an interview on 11/19/25, at 1:30 p.m., Corporate Infection Control Employee E16 stated that due to
the frequent changes in the facility management team and change in ownership, the Infection
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395732
If continuation sheet
Page 35 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Control practices, antibiotic stewardship monitoring and the offering/provision of vaccines had not been
completed and the facility failed to failed to complete Infection Control surveillance from November 2024
through November 2025, failed to monitor Antibiotic Stewardship for May 2025 and failed to provide
vaccines for flu, pneumonia and COVID-19 to 105 of 105 residents for the 2025 season, resulting in
substandard quality of care.
Residents Affected - Many
28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa.
Code: 211.10 (d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395732
If continuation sheet
Page 36 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0881
Implement a program that monitors antibiotic use.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of the facility's infection control policies and procedures and staff interview, it was
determined that the facility failed to implement an antibiotic stewardship program for one of 11 months (May
2025). Findings include:Review of facility policy Antibiotic Stewardship Program dated 10/17/25, with a
previous review date of 9/25/24, indicated usage and outcome data will be collected and documented using
a facility tracking form and will guide decisions for improvement of individual resident antibiotic prescribing
practices and facility wide antibiotic stewardship.Review of the facility's Infection Control surveillance for
December 2024 through November 2025 failed to include documentation to indicate that antibiotic
monitoring was completed for May 2025.Interview on 11/19/25, at 1:30 p.m., the Corporate Infection
Control Nurse Employee E16 confirmed that the facility failed implement an antibiotic stewardship program
for one of 11 months (May 2025). 28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code:
211.12(d)(1)(2)(3)(5) Nursing services.
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395732
If continuation sheet
Page 37 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm
or potential for actual harm
Based on a review of facility policies and procedures, current Centers for Disease Control (CDC)
guidelines, clinical record review, and staff interview, it was determined that the facility failed to document
each resident was offered an influenza and/or pneumococcal immunization and the resident or resident's
representative was provided education regarding the benefits and potential side effects of immunizations,
for 105 of 105 residents reviewed for influenza and pneumococcal immunizations resulting in substandard
quality of care. Findings include:A review of facility policies, Pneumococcal Vaccine and Influenza Vaccine,
dated 10/17/25, with a previous review date of 9/25/24, indicated vaccines are administered in accordance
with Centers for Disease Control and Prevention (CDC) recommendations. All residents are offered
pneumococcal and influenza vaccines to aid in preventing infections. The resident or resident's legal
representative will be provided information and education regarding the benefits and potential side effects
of the vaccines and will be documented in the medical record. During an interview on 11/19/25, at 1:30
p.m., Corporate Infection Control Employee E16 stated that due to the frequent changes in the facility
management team and change in ownership, the offering/provision of the flu and pneumonia vaccines had
not been completed and the facility failed to document each resident was offered an influenza and/or
pneumococcal immunization and the resident or resident's representative was provided education
regarding the benefits and potential side effects of immunizations, for 105 of 105 residents reviewed for
influenza and pneumococcal immunizations resulting in substandard quality of care. 28 Pa. Code
211.5(f)(i)-(xi) Medical records.28 Pa. Code 211.12(d)(1)(5) Nursing services
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395732
If continuation sheet
Page 38 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0887
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and
staff after education, and properly document each resident and staff member's vaccination status.
Based on review of clinical records and interview with staff, it was determined that facility failed to ensure to
provide pertinent information regarding the immunizations to the resident or the resident's representative
such as the benefits and potential side effects of the covid-19 immunizations for 105 of 105 residents.
Findings include:During review of the Infection Control Practices for the 2025 vaccine documentation did
not include pertinent information regarding the immunizations to the resident or the resident's
representative such as the benefits and potential side effects of the covid-19 immunizations for 105 of 105
residents. During an interview on 11/19/25, at 1:30 p.m., Corporate Infection Control Employee E16 stated
that due to the frequent changes in the facility management team and change in ownership, the facility
failed to ensure to provide pertinent information regarding the immunizations to the resident or the
resident's representative such as the benefits and potential side effects of the covid-19 immunizations for
105 of 105 residents. 28 Pa Code 201.14(a) Responsibility of licensee28 Pa Code 201.18(b)(1)
Management28 Pa Code 211.15(f) Clinical records
Event ID:
Facility ID:
395732
If continuation sheet
Page 39 of 40
Printed: 05/15/2026
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
395732
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2025
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)
F 0908
Keep all essential equipment working safely.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations and staff interviews, it was determined that the facility failed to ensure the dish
machine was in proper working order in the Main Kitchen. Findings include: During an observation of the
dish room on 11/17/25, at 10:00 a.m. the final rinse temperature indicated 140 degrees Fahrenheit. Dish
washer temperature verification strip did not change color indicating not meeting the proper rinse
temperature of 160 degrees Fahrenheit. During an interview on 11/17/25, at 10:15 a.m. Dietary Manager
Employee E8 confirmed he was not aware that the dishwasher was inoperable and directed staff to use
Styrofoam containers and cups. Dietary Manager Employee E8 stated Maintenance staff looked at the dish
machine and it needed a new motor and would be down. During an interview on 11/18/25, at approximately
2:00 p.m. the Dietary Manager Employee E8 confirmed the facility failed to ensure the dish machine was in
proper working order in the Main Kitchen. 28 Pa Code:201.14(a) Responsibility of Licensee
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395732
If continuation sheet
Page 40 of 40
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
30 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F585 - Grievances
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
F694 - Parenteral Fluids
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
F806 - Food and drink
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
F810 - Assistive devices
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
F865 - Quality assurance and performance improvement (QAPI) program
Have a plan that describes the process for conducting QAPI and QAA activities.
F868 - Quality assessment and assurance
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
F880 - Infection Control
Provide and implement an infection prevention and control program.
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F887 - Infection control
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.
F554 - The right to self-administer medications if the interdisciplinary team, as
Allow residents to self-administer drugs if determined clinically appropriate.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F575 - The facility must post, in a form and manner accessible and understandable
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
F576 - The resident has the right to have reasonable access to the use of a telephone,
Ensure residents have reasonable access to and privacy in their use of communication methods.
FAQ · About this visit
Common questions about this visit
What happened during the November 21, 2025 survey of HERITAGE CARE CENTER?
This was a inspection survey of HERITAGE CARE CENTER on November 21, 2025. The surveyor cited 30 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at HERITAGE CARE CENTER on November 21, 2025?
Yes, 30 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) tha..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.