Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heritage Green Rehab & Skilled Nursing during CMS and state inspections, most recent first.
Surveyors found that the facility used the DON as a charge/staff nurse to meet minimal staffing levels even when the census was well above 60 residents. Staffing records showed the DON was scheduled as the second nurse on a unit and, at times, functioned as the only nurse on that unit, despite a written requirement for two nurses per shift. The DON and scheduler reported that the DON regularly filled in as a CNA, housekeeper, or medication nurse when staffing was short, and the scheduler was unaware that the DON should not function outside the DON role under these census conditions.
The facility did not maintain enough nursing staff to meet resident needs across shifts. Residents and families reported long call bell waits, delayed toileting, missed or late meals, and difficulty getting help with transfers and feeding. Staff described working with only one or two aides on a unit, staying late to finish duties, and being unable to complete all care tasks on time. Observations showed delayed tray passing and a resident waiting on the toilet for an extended period before staff returned with a mechanical lift.
Surveyors found that side rails were not properly assessed, documented, or maintained for three residents. One resident had loose quarter rails on the bed even though the care plan said no rails, another had loose rails that were on the care plan but had no documented routine maintenance, and a third had a quarter rail up despite a care plan showing no rails. Staff and leadership stated the rails should have been identified through assessments, care plan review, and maintenance checks, but documentation was missing or inconsistent.
A resident with CHF, HTN, and COPD had potassium chloride left on the bedside table instead of being directly observed as taken, while the MAR documented the medication as administered. The resident said staff brought the pills in the morning and they saved them for later, and staff interviews confirmed the medication was left in the room without an order for self-administration. The DON and RN manager stated meds were not to be left unattended and nurses were expected to stay until all meds were taken.
A resident with CHF, HTN, and COPD had potassium chloride pills left unsecured in a small container on the bedside table without an order to self-administer or keep meds at bedside. Staff observed the pills there over multiple days, and both the RN manager and DON stated meds were not to be left with residents without a physician order.
Cold and unappetizing meals were served on two unit test trays after tray line delays and inconsistent temperature monitoring. Residents reported cold food, lukewarm coffee, poor taste, and small portions, while surveyors observed reheating, item substitutions, and a shortage of clean plates that delayed service. On both trays, pork and stuffing were served below expected hot-holding temperatures and were described as lukewarm, cold, dry, or lacking flavor.
Survey results were not posted in a readily accessible location and the binder was stored behind the reception desk with other binders, making it unavailable for residents and visitors to easily review. The binder contained only the most recent CMS-2567 and did not include all complaint investigation results with POCs for the past 3 years. Several residents stated they did not know where to find the survey results and wanted to review them.
The facility did not provide adequate nursing staff daily to meet all residents' needs and failed to have a licensed nurse in charge on every shift, resulting in noncompliance with staffing regulations.
A resident who had declined the COVID-19 vaccine was mistakenly administered the vaccine after an LPN failed to verify the resident's identity according to facility policy. The error was confirmed by staff interviews and documentation, revealing a violation of the resident's right to refuse treatment.
DON Inappropriately Used as Charge Nurse at High Census
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the Director of Nursing (DON) did not serve as a charge nurse when the facility’s average daily census exceeded 60 residents, as required by 10 NYCRR 415.13(b)(1). The DON job description stated that the DON was responsible for planning, directing, and coordinating nursing services, managing resident care 24 hours a day, seven days a week, and ensuring a sufficient number of qualified supervisory and supportive nursing personnel on each tour of duty. Census reports showed that during the review period the facility census ranged from 113 to 116 residents, and at survey entrance the census was 115 out of 135 beds. Despite this census level, daily staffing sheets from late January to mid-February documented that the DON was counted in the facility’s minimum staffing numbers for direct resident care. On specific evening shifts, the DON worked on a named unit from 6:00 PM to 10:00 PM as the second nurse, and on one of those dates, from 9:21 PM to 10:00 PM, the DON was the only nurse on the unit. The facility’s minimal staffing document required two nurses on that unit for the day and evening shifts, and the DON was used to meet those minimums. In interviews, the Facility Scheduler stated they were unaware that the DON was not supposed to act outside the DON role and acknowledged that the DON was used as staff when coverage could not be found, noting that the minimum staffing numbers were not ideal for completing work and providing good care. The DON reported not knowing the exact regulation, believing the practice was merely frowned upon, and stated they frequently acted as a CNA, housekeeper, or medication nurse while remaining available as DON. The Administrator confirmed that minimum staffing numbers were not the goal and that leadership was willing to help staff and residents when needed.
Insufficient Nursing Staff and Delayed Resident Care
Penalty
Summary
The facility did not ensure sufficient nursing staff were available on a 24-hour basis to meet resident needs and maintain resident well-being. The facility assessment and QAPI review documented a 134-bed facility with a secure dementia unit, a long-term care unit, and a short-term rehab unit, and identified staffing needs based on resident acuity, census, odors, complaints, call lights, and staff ability to complete assignments. The staffing plan called for specific minimum numbers of nurses and nurse aides on each shift, but the daily staffing sheets showed the Director of Nursing was counted toward direct care staffing numbers. The facility was also rated one star for staffing in the PBJ report and triggered for low staffing levels on weekends. Residents and family members described long waits for call lights, delayed toileting assistance, missed or delayed meals, and difficulty getting help with transfers and other basic care. One resident reported waiting almost three hours for a call light to be answered and often making their own bed because staff did not get to it in time. Another resident reported waiting over an hour to use the bathroom and then incontinent in their brief because staff said they did not have enough help. A resident council meeting included multiple residents who agreed there were not enough CNAs in the building, and one resident stated two staff were sometimes not used for mechanical lift transfers even though two were required. Family members also reported long call bell wait times and concerns that residents were not getting to the bathroom in time. Observations and staff interviews showed delays in routine care and meal service that were linked to limited staffing. During a dining observation, a meal cart was delivered but trays were not started for several minutes, and staff and family reported food often sat too long before being passed, resulting in cold meals. A resident was observed waiting on the toilet for 34 minutes before staff returned with a mechanical lift. Staff repeatedly stated they were working with only one or two aides on a unit, had to stay late to finish work and documentation, and could not always complete showers, toileting, feeding, or transfers on time. The DON, Administrator, and other leaders acknowledged the minimum staffing was not ideal and that long call bell wait times and staffing concerns were ongoing.
Bed Rails Installed or Left in Place Without Proper Assessment, Care Planning, or Maintenance Documentation
Penalty
Summary
The facility failed to assess all residents for the risk of entrapment from bed rails before installation and failed to provide documentation of routine preventive maintenance for bed rails for three residents reviewed. The report also found that quarter side rails were installed in error for two residents and were not reflected on the care plan. The facility policy required side rail safety assessments on admission, quarterly reassessment for residents using side rails, discussion of risks and benefits, informed consent, and maintenance review to ensure the bed and rail system passed an entrapment assessment. One resident had diagnoses including wedge fractures, difficulty walking, and cognitive communication deficit. Although the resident’s care plan and prior side rail assessments documented no side rails, observations on multiple days showed gray plastic side rails on both sides of the upper portion of the bed. Both rails were loose and wobbly. The resident stated they used the bed rails to get into bed at night and had not seen anyone check the side rails. The resident’s daughter stated the rails had been on the bed the whole time. The DON stated the resident should not have had the side rails and that someone should have noticed they were present even though they were not on the care plan. A second resident had diagnoses including Fournier gangrene, diabetes mellitus, and morbid obesity. The resident’s care plan documented two upper side rails, and the side rail assessment documented the resident had two upper side rails and discussed entrapment risks with the resident/family. However, observations showed two gray quarter side rails up on both sides of the bed, and both were loose and wobbly. The resident stated they used the side rails for bed mobility and that the rails had been there for three years without anyone checking to ensure they were secured. A CNA later observed the rails and stated they were loose. A third resident had diagnoses including dementia, pneumonia, and anxiety. The resident’s care plan documented no side rails, and the side rail assessment also documented no side rails. Despite this, observations showed one quarter side rail up on the left side of the bed while the resident was asleep. Maintenance provided logs and worksheets, but the records showed no documented routine preventive maintenance for the side rails and no current entrapment check documentation. Maintenance staff stated they visually checked side rails every six months but had no documentation of routine inspections, and the DON stated maintenance should have kept track of preventive maintenance documentation.
Medication Left at Bedside and Documented as Administered
Penalty
Summary
Services provided by the facility did not meet professional standards of quality for one resident when prescribed medications were not administered as ordered and were left unattended at the bedside. Resident #82 had diagnoses including congestive heart failure, hypertension, and chronic obstructive pulmonary disease, and was documented as cognitively intact, alert, and oriented x3. The care plan stated medications were to be administered as ordered, and the physician ordered Potassium Chloride 20 milliequivalents once daily in the morning. During observation, two yellow pills identified as potassium were seen on the resident’s bedside table in a small clear plastic container. The resident stated the nurses brought the medication in the morning and that they put it aside to take later before bed. Intermittent observations over several days continued to show the same two pills on the bedside table. The Medication Administration Record documented the potassium as administered on multiple mornings, even though the pills remained visible in the resident’s room. Interviews with nursing staff showed that one LPN stated the resident had pills left in the room and that the nurse did not check back to confirm all medications were taken. Another LPN stated the resident preferred to take potassium after breakfast and that the pills were left in the room, with follow-up later to witness ingestion. The RN manager and DON stated nurses were expected to stay with residents until all medications were taken, that medications were not to be left at the bedside without a physician order, and that Resident #82 did not have an order to self-administer potassium.
Unsecured Medication Left at Bedside Without Order
Penalty
Summary
Drugs and biologicals were not securely stored for one resident. Resident #82, who had diagnoses including congestive heart failure, hypertension, and chronic obstructive pulmonary disease, was cognitively intact and documented as alert and oriented x3. The resident’s care plan stated medications were to be administered as ordered, but it did not document that the resident preferred or was able to self-administer medications. Physician orders reviewed for the relevant period did not include an order for self-administration or for medications to be left at the bedside. During observation, two yellow potassium chloride pills were seen in a small clear plastic container with a lid on the resident’s bedside table, and the resident stated the nurses brought the medication in the morning and the resident put it aside to take later before bed. The pills remained on the bedside table during repeated observations over several days. An LPN identified the pills as potassium chloride, another LPN stated the resident preferred to take the medication after breakfast and kept it in a container on the bedside table, and the RN manager and DON stated medications were not to be left with residents without a physician order and that Resident #82 did not have an order to self-administer medications.
Cold and Unappetizing Meals Served During Tray Line Delays
Penalty
Summary
Food and drink were not palatable and were not served at a safe and appetizing temperature for two of three unit test trays observed, involving residents on the Park Unit and Lake Unit. Facility policies stated that hot foods were to be heated to at least 165 degrees Fahrenheit and held at 140 degrees Fahrenheit or higher until service, and that trays were to be served promptly. During resident interviews, multiple residents stated the food was cold, lacked taste, and was often served with insufficient portions; one resident said the coffee was always cold, another said breakfast was especially cold, and another described the food as terrible and not decent. During a continuous observation of the kitchen lunch tray line, surveyors saw multiple delays, including gravy needing to be reheated, a vegetable item running out and being substituted, and clean plates running out mid-service, which delayed carts leaving the kitchen. On the Park Unit, the lunch test tray arrived at 12:52 PM and all trays were passed by 12:54 PM, but the pork measured 89.5 degrees Fahrenheit and tasted cold and dry, and the stuffing measured 122.9 degrees Fahrenheit and tasted lukewarm. The Director of Food Service stated the pork had been 172 degrees Fahrenheit at the start of tray line and should have been at least 120 degrees Fahrenheit when the cart reached the unit, and noted that new staff learning different positions contributed to the delay. On the Lake Unit, the lunch test tray cart arrived at 1:00 PM and trays were passed by 1:08 PM, but the pork with gravy measured 112.9 degrees Fahrenheit and the stuffing with gravy measured 110 degrees Fahrenheit; both were described as lukewarm and lacking flavor. The Director of Food Service stated both items should have been served at 120 degrees Fahrenheit or higher and acknowledged difficulty maintaining temperature for pureed foods once plated. Additional interviews confirmed that staff did not take mid-tray-line temperatures, that trays often sat for extended periods before being passed on the units, and that the facility had been receiving complaints about cold food and was auditing test trays more frequently because of those complaints.
Survey Results Not Readily Accessible
Penalty
Summary
The facility did not ensure that the results of the most recent health surveys were posted in a place readily accessible to residents, family members, and legal representatives. During the survey, the facility’s past survey results were found in a binder stored behind the reception desk with other binders, and the binder was not visible or labeled in a way that made it easy to identify. Social Worker #1 stated the survey results were not in a place readily accessible to residents and visitors without having to ask for them, and the Administrator also stated the binder was not in an easily accessible location when stored behind the reception desk with other binders. The binder contained the CMS-2567 from the 02/01/2024 recertification survey, but it did not contain all complaint investigation results with plans of correction for the past three years. The Administrator stated the facility had a complaint survey requiring a plan of correction after the last recertification survey, but those results were not in the binder. During the resident council meeting, Residents #1, #43, #60, #79, and #85 stated they were unsure whether the facility posted past survey results or where to find them, and they were interested in reviewing them.
Insufficient Nursing Staff and Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified based on observations and findings that indicated staffing levels and licensed nurse coverage were insufficient to comply with regulatory requirements.
COVID-19 Vaccine Administered Without Consent Due to Resident Misidentification
Penalty
Summary
A resident with diagnoses including dementia, depression, and hypertension, who was assessed as cognitively intact, was administered the COVID-19 vaccine despite having signed a declination form indicating refusal of the vaccine. Facility policy required that consent or declination for the COVID-19 vaccination be obtained and documented within seven days of admission, and that residents or their responsible parties have the right to refuse any vaccination at any time, with all education and refusals documented in the medical record. The resident's signed declination was present in the record, and the COVID-19 vaccine was nonetheless administered. The incident occurred when an LPN failed to verify the resident's identity by not checking the wristband prior to administering the vaccine, as required by the facility's medication administration policy. Documentation in the medical record confirmed the administration of the vaccine and a subsequent medication error report noted the failure to follow resident rights and proper identification procedures. Interviews with facility staff, including the LPN, the infection preventionist RN, and the Director of Nursing, confirmed that the vaccine was given in error and that this action violated the resident's right to refuse treatment.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Greenhurst
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Park Rehab & Skilled Nursing | 4.3 mi | ★★★★★ | 1 | 0 |
| Heritage Village Rehab And Skilled Nursing Inc. | 8.9 mi | ★★★★★ | 0 | 0 |
| Rouse Warren County Home | 19.3 mi | ★★★★★ | 5 | 0 |
| Absolut Ctr For Nursing & Rehab Westfield L L C | 19.5 mi | — | 0 | 0 |
| Kinzua Nursing And Rehab | 21 mi | ★★★★★ | 8 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.