Heritage Green Rehab & Skilled Nursing

In the surveyor’s words

From the most serious findings on record at Heritage Green Rehab & Skilled Nursing, in the surveyor’s own words.

• Immediate jeopardy, patternF725Dec 7, 2021

  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. […]

• No harm, potential for more than minimal, widespreadF725Feb 27, 2026

  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. […]

• No harm, potential for more than minimal, widespreadF727Feb 27, 2026

  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. […]

• No harm, potential for more than minimal, widespreadF725Aug 15, 2025

  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… […]

• No harm, potential for more than minimal, patternF700Feb 27, 2026

  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). […]