Heritage Green Rehab & Skilled Nursing

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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). [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]