Heritage Green Rehab & Skilled Nursing
3023 Route 430, Greenhurst, NY 14742 · Non profit - Corporation · 134 certified beds · (716) 483-5000 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 18.2% | 14.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.5% | 5.8% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 2.7% | 0.5% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.6% | 1.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.9% | 19.5% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.7% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 24.7% | 12.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 8.8% | 13.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 94.6% | 95.3% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.5% | 6.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 16.4% | 19.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 25.0% | 13.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 68.0% | 78.8% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 19.7% | 20.6% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 16.0% | 9.6% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.10 | 1.70 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.11 | 1.36 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
44.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 139 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 55.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 81 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.36 therapist hours per resident per day in 2026Q1 — more than 62% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 44.2%CMS range 35.8–51.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.9%CMS range 8.1–15.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 55.6% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 44.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 66.7% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.2%CMS range 2.4–9.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.96 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 134 beds and averages 116.1 residents a day — about 87% occupied, or roughly 18 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.42 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.32 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.14 hrs/resident/day on weekends vs 2.53 on weekdays — 15% thinner on weekends. RN hours go from 0.39 to 0.14 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 51% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
16 citations, most serious first. The 11 most serious are shown; the remaining 5 are one tap away and print in full.
- Immediate jeopardy · Kcited before2021-12-07 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during a Recertification Survey completed on 12/7/21, the facility failed to ensure sufficient nursing staff with appropriate competencies and skill sets to provide nursing and related services and safety to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for residents on 1 of 3 units reviewed. Specifically, on 12/1/21 the Registered Nurse Supervisor (RNS) #3 Nurse Supervisor, was scheduled as the facility supervisor and the sole nurse on the Lake Unit. RNS #3 was not able to complete the medication pass timely, as the RN was assigned additional duties due to staff shortage on one (Lake Unit) of three units, that delayed medication pass. Resident (#1) with history of seizures did not receive medications timely. Resident (#2) with history of diabetes did not receive medications timely. Resident (#3) with history of hypertension…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-02-27 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record review conducted during a survey the facility did not ensure there was sufficient staff on a 24-hour basis to attain or maintain the highest practicable physical, mental and psychosocial well-being for residents in the facility. Residents #1, 2, 5, 7, 22, 37, 43, 60, 71, 76, 79 and 85 involved. The findings are: The Facility Assessment with a completed date of 02/16/2026, and a QAA (Quality Assessment and Assurance)/QAPI (Quality Assurance and Performance Improvement) review completed 8/26/2025 documented the facility has a secure dementia care unit (41 beds), long-term care unit compromised of 42 beds and another 51 bed that admits primarily short- term rehab. At least 65 percent of the facility's residents needed some assistance with dressing and bathing, 88 percent of residents needed some assistance with transfers, 93 percent needed some assistance with toileting, and 30 percent of residents needed some assistance with eating. The facility will ensure that there…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-02-27 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review conducted during a survey the facility did not ensure the Director of Nursing served as a charge nurse, only when the facility had an average daily occupancy of 60 or fewer residents. Specifically, the Director of Nursing worked as a charge nurse when the facility had a daily average census of greater than 60. The findings are:Review of the undated document titled Director of Nursing Job Description documented that within the framework of the objectives and policies established by the Corporation, and the New York State Department of Health regulations, the Director of Nursing is responsible for planning, directing, and coordinating nursing services. Under the supervision of the Administrator, the Director of Nursing exercises authority, responsibility and accountability for the functions, activities and training of the nursing service staff. Participates as a member of the facility management team in planning, policy formulation, and administrative decision making with particular reference to the role, function, and operation of the facility's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-02-27 · tag F0700 — patternTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the Standard survey completed on 02/27/2026, the facility did not ensure: they assessed all residents for risk of entrapment from bed rails prior to installation, or provide documentation that preventive maintenance was conducted for all bed rails for three (3) (Residents #5,14, and 118) of three (3) residents reviewed. Specifically, the quarter side rails were loose and not secure (Resident's #5 and #14); and there was no documented evidence of routine preventative maintenance (Resident #5, 14, & 118). In addition, the quarter side rails were installed in error and not reflected on the care plan (Resident #5 and #118). The findings are: The policy and procedure titled Side Rail Use revised 10/2021 documented the intent of this policy and procedure is to provide a safe bed environment through assessment and planning of each resident's needs. Side Rail Safety Assessments shall be completed upon admission. Residents who are care planned to use…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-27 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interviews during a survey, the facility did not ensure that services provided or arranged by the facility met the current professional standards of quality for one (Resident #82) of one resident reviewed. Specifically, Resident #82's medications were not administered as per the physician's order, medications were left on resident's overbed table, and nursing staff documented that the medications were administered in the Medication Administration Record. The findings are. Refer to F 761 scope and severity = D The policy and procedure titled Medication Administration dated 10/17/2019 documented only licensed nurses shall prepare and administer medications. The designated licensed nurse shall prepare medications immediately prior to administration; be certain that the resident takes the prescribed medication in their presence; and never leave any medication in the resident's possession or at the bedside unless the physician orders in writing, state to do so. Each medication given is to be recorded on the resident's medication record. The policy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-27 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review conducted during a the facility did not ensure that drugs and biologicals were securely store in accordance with State and Federal laws for one (1) (Resident #82) of one (1) reviewed. Specifically, Resident #82 had medications stored and unsecured on an over the bed table in their room.The findings are:Refer to F 658 scope and severity= DThe policy and procedure titled Medication Administration dated 10/17/2019 documented the designated licensed nurse shall never leave any medication in the resident's possession or at the bedside unless the physician orders in writing, state to do so.Resident #82 had diagnoses that included congested heat failure (a condition where the heart is too weak to pump blood), hypertension (high blood pressure), and chronic obstructive pulmonary disease (chronic lung disease). The Minimum Data Set (a resident assessment) dated 02/06/2026 documented Resident #82 was cognitively intact, was understood and understands others.The comprehensive care plan dated 01/30/2026 documented Resident #82 was alert and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-27 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review conducted during the survey, the facility did not provide food and drink that was palatable and served at a safe and appetizing temperature for two (2) (Park Unit and Lake Unit) of three (3) unit test trays. Specifically, food and beverages during meals were served at suboptimal temperatures and were not palatable. Residents #8, 11, 32, 37, 41, and 71 were involved. The findings are:The policy titled Food Safety Requirements dated 06/13/2018, documented it is important to focus attention on the risks that are associated with foodborne illness by identifying critical control points in the food preparation processes that, if not controlled, might result in food safety hazards including, thawing, cooking, cooling, holding, reheating of foods, and employee hygienic practices.The policy titled Mealtime Procedure revised on 06/23/2015, documented to serve the tray so that trays may be served promptly - all nursing personnel are expected to assist.The policy titled Food Preparation dated 09/20/2002, documented foods will be heated to a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-08-15 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review conducted during a Complaint investigation (NY00384369-530162, NY00384458-530191, NY00385240-530194) completed on 08/15/2025, the facility did not ensure sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, the facility did not ensure there was sufficient nurse staffing to meet the needs of the resident in accordance with their preferences and plans of care.The finding is:Review of the Dear Administrator letter 23-11 dated 06/30/23 sent to the nursing home administrators informing them that starting 04/01/2022 nursing homes were required to have an average daily staffing of 3.5 hours of care per resident per day with 2.2 hours for Certified Nurse Aides and 1.1 hours for Licensed Practical Nurses or Registered Nurses.The Facility Assessment, review dated 04/28/2025, documented the assessment is required by the nursing home Requirements of Participation to identify and analyze the facility's resident population and identify the personnel,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-15 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review conducted during a Complaint investigation (#NY00364661-530180), the facility did not ensure that a resident has the right to refuse treatment for one (1) (Resident #1) of six (6) residents reviewed for immunizations. Specifically, Resident #1 was administered the COVID-19 vaccine without consent.The finding is:The policy and procedure titled Standing Order for Provision of Influenza, Pneumococcal, and COVID-19 Vaccine, revised 01/06/2024 documented all residents will be screened upon admission to the facility to evaluate COVID-19 immunization status. Consent or declination of the COVID-19 vaccination will be obtained within seven (7) days of admission and documented in the medical record. Residents or responsible parties have the right to refuse any vaccination at any time, education and refusals will be documented in the medical record.The policy and procedure titled Medication Administration revision/reviewed dated 12/09/2024 documented to check the resident wristband or bracelet or badge before administering the medication to make accurate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-01 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the Standard survey completed on [DATE], the facility did not ensure the system developed for advanced directives was implemented in a manner that was consistent with resident's wishes for one (Resident #62) of one resident reviewed for advanced directives. Specifically, the facility did not ensure that all resident advanced directives identifiers were consistent with the resident wishes. Additionally, there was no development of a care plan for advanced directives. The findings are: The undated policy and procedure titled Medical Orders for Life Sustaining Treatment (MOLST) documented honoring patient preferences was a critical element in providing quality end of life care. Residents who wish to be a FULL CODE (cardiopulmonary resuscitation) per their Medical Orders for Life Sustaining Treatment (MOLST) form will have a blue sticker on their nameplate, physical chart, blue wristband and resuscitate listed in the electronic medical record. A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-01 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review conducted during a standard survey completed on 2/1/24, the facility did not ensure that the provider was notified of a need to alter treatment, or to commence a new form of treatment, for one (Resident #61) of one resident reviewed. Specifically, staff did not notify the provider when Resident #61's ACE wraps were not applied to both lower extremities on multiple occasions as ordered. The finding is: Per the Director of Nursing, the facility did not have a policy and procedure for the application of ACE wraps for edema (swelling caused be excess fluid accumulation). The policy and procedure titled Anti-Embolism Stockings, dated 1/14/2015, documented that the garment should be applied in the morning, before swelling occurs. Resident #61 had diagnoses including unspecified dementia without behaviors, localized edema, and type II diabetes mellitus. The minimum data set (a resident assessment tool) dated 1/3/24, documented Resident #61 was cognitively intact, usually understood and usually understands. Resident #61's Physician Orders…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 5 citations
- Potential for harm · D2024-02-01 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review conducted during a Standard survey completed on 2/1/24, it was determined that the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for one (Resident #90) of five residents reviewed. Specifically, the resident was observed with ½ inch to one-inch-long whiskers on their chin and neck. The policy and procedure titled Activities of Daily Living dated 1/14/15 documented the nursing staff will assist the resident with any activities he/she was unable to perform by him/herself. Resident #90 had diagnoses of dementia and seizure disorder. The Minimum Data Set (a resident assessment tool) dated 12/13/23 documented Resident #90 was severely cognitively impaired and required substantial/maximal assistance of a helper with more than half the effort to perform personal hygiene. During an observation on 1/28/24 at 11:58 AM, Resident #90 had multiple ½ inch long, white hairs on their chin and one-inch-long white hairs on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during a Complaint investigation (Complaint #NY00330011) during the Standard survey completed 2/1/24, the facility did not ensure that each resident receives adequate supervision to prevent accidents for one (Resident #39) of three residents reviewed for elopement. Specifically, Resident #39, eloped from the facility on 12/16/23, did not have an elopement risk assessment completed since 2021, and had no care plan interventions to address their wandering behaviors prior to the elopement incident. The finding is: The policy and procedure, Unsafe Wandering Elopement Risk revised 11/3/2016, documented the facility was to provide a safe and secure environment for all residents. Unsafe wandering/elopement risk assessment will be done on all new admissions in conjunction with the initial Minimum Data Set (a resident assessment tool). Subsequent use would be in conjunction with any onset of wandering behaviors. Individualized care plans will be developed for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-01 · tag F0742 — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review conducted during a Standard survey completed on 2/1/24, the facility did not ensure that each resident received the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being for one (Resident #60) of one resident reviewed. Specifically, a Psychiatry consult was not followed up on and/or implemented. Additionally, there was a lack of care plan development for a history of sexual trauma. The finding is: The policy and procedure titled Antipsychotic Drugs revised 12/23/13 documented to obtain psychiatric or psychological consultation whenever necessary to establish a diagnosis or alternative treatment program. The policy and procedure titled Computerized Care Plan revised 1/14/15 documented that care plans should reflect the facility's approach to a problem and will be updated as needed. During an interview on 2/1/24 at 1:05 PM, Director of Nursing stated they had no policy and procedures related to consultations or psychiatry consult recommendations. Resident #60 had diagnoses…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-12-07 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review conducted during the Standard survey completed on 12/7/21, the facility did not ensure residents are free of any significant medication error for one (Resident #4) of 4 medication pass observations. Specifically, Resident #4 with history of gastrointestinal distress did not receive medications as ordered and in accordance with facility practices. The finding is: The policy and procedure (P&P) titled Medication Administration Schedule dated 2/25/2015 documented the Licensed Nurse (RN, LPN (licensed practical nurse)) was responsible for adhering to the Standard Medication Administration time codes which are used in each long-term care facility to indicate when medications are to be given to their residents. Unless a specific hour is ordered, all medication will be given within established standard time codes. Medications ordered to be given at a specific time will be administered within one hour of that time. 1. Resident #4 had diagnoses which included gout (a type of arthritis that causes inflammation of joint), protein-calorie…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2026-02-27 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews and record review during the survey, the facility did not ensure the results of the most recent health surveys were posted in a place readily accessible to residents, family members, and legal representatives of residents. Specifically, the facility's past survey results were located in a binder stored behind the reception desk with other binders and were not readily accessible. Additionally, the facility's past survey results binder did not contain all complaint investigation results with plan of corrections for the past three (3) years. Residents #1, 43, 60, 79, and 85 were involved. The finding is:The facility's policy titled Required Postings and Bulletin Board, dated 9/23/2009 documented the required postings on unit bulletin boards were to contain the results of the most recent New York State Health Department Survey of the facility.The State Operations Manual dated 07/23/2025 documented the definition for a Place readily accessible is a place (such as a lobby or other area frequented by most residents, visitors or other individuals) where…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to HERITAGE MINISTRIES — 3 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.0 | -1.0 vs chain |
| Health inspection | 2 of 5 | 2.0 | ≈ chain avg |
| Staffing | 1 of 5 | 2.0 | -1.0 vs chain |
| Quality measures | 2 of 5 | 3.0 | -1.0 vs chain |
The other 2 homes this chain runs (chain average 2.0★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| HERITAGE MINISTRIES CHARITABLE CARE NETWORK INC. | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 08/11/2008 |
| FERNANDEZ, GREGORY | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 11/25/2024 |
| NOLL, PAMELA | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 11/25/2024 |
| SPANOS, MARY ANN | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 11/25/2024 |
| STARK, PETER | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 11/25/2024 |
| HAGLUND, LISA | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/11/2020 |
| BURKHOUSE, JESSICA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/14/2014 |
| DIGREGORIO, ROBIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/25/2024 |
| PERSIA, ALBERT | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/24/2023 |
| WILCOX, MARK | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 11/25/2024 |
CMS files one row per role, so the 19 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 73% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NY
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New York Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 335721. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-27, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.