Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Village Rehab And Skilled Nursing Inc. during CMS and state inspections, most recent first.
The facility failed to maintain sufficient nursing staff, leading to inadequate care for residents. Observations and interviews revealed that residents often did not receive timely incontinence care or assistance with meals due to staffing shortages. Despite being aware of the issue, the facility's administration struggled to meet the minimum staffing requirements, impacting the quality of care.
Several residents in the facility were neglected in terms of incontinence care, with staff failing to provide timely checks and changes due to staffing issues. Residents with severe cognitive impairments were left in saturated briefs for extended periods, contrary to their care plans. Staff interviews revealed a lack of clear policy direction and insufficient staffing as contributing factors to the neglect.
The facility's QAPI program failed to address ongoing staffing deficiencies, despite awareness from administration and concerns from staff and residents. The facility struggled to meet minimum staffing numbers, impacting resident care, as documented in reports and interviews with key personnel.
The facility did not maintain the required RN coverage for 8 consecutive hours on three occasions, as mandated by regulations. Despite being aware of the deficiency, the facility's staff, including the Scheduler, Acting DON, and Administrator, were unable to secure the necessary coverage, and no waiver was in place.
The facility failed to resolve grievances for missing personal property for two residents. One resident reported missing clothing items, and another reported a missing razor and trimmer. Despite notifying staff, no grievance forms were filed, and there was no follow-up or resolution. The facility's grievance policy was not followed, and the Administrator was unaware of the issues.
Two residents in an LTC facility did not receive necessary assistance with daily living activities, leading to deficiencies in nutrition and grooming. A resident with Parkinson's and dysphagia was left unsupervised during meals despite needing assistance, consuming only half of their meals. Another resident, dependent on staff for personal hygiene, had facial hair that was not removed, raising dignity concerns. Staff interviews confirmed these oversights, indicating a failure to follow care plans and facility protocols.
A facility failed to ensure proper action and documentation of a pharmacist's medication recommendations for a resident with Alzheimer's and other cognitive impairments. The pharmacist recommended gradual dose reductions and discontinuation of certain medications, but these were not consistently followed or documented by the medical staff. Interviews revealed a lack of clarity and communication among staff regarding the process, leading to the resident continuing on medications without proper review.
The facility failed to post daily nursing staff information with required details, such as resident census and actual hours worked, during a survey. Observations showed incomplete reports, and staff interviews revealed a lack of training and understanding of the process. This deficiency violated 10 NYCRR 415.13.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the needs of its residents, as observed during an Extended Recertification Survey. The facility's staffing levels did not meet the minimum requirements established in their Facility Assessment, which indicated a need for 8 Licensed Practical Nurses, 15 Certified Nurse Aides, and 1 Registered Nurse for the current census. The daily staffing sheets revealed numerous instances where the facility was understaffed, particularly in terms of Certified Nurse Aides and Registered Nurses, across various shifts from late June to early August. Residents and staff reported significant issues due to the staffing shortages. Residents expressed concerns about not receiving timely care, such as incontinence care and assistance with meals. Specific incidents included a resident being left on the toilet for two hours and others not receiving incontinence care for extended periods, resulting in them being left in soiled clothing. Staff interviews corroborated these issues, with aides and nurses frequently reporting that they were unable to complete their duties due to the low staffing levels. The facility's administration and corporate management were aware of these staffing issues, as indicated by multiple staff reports and meetings. The Resident Council and Ombudsman also highlighted ongoing concerns about staffing, with residents complaining about missed showers and inadequate care. Observations during the survey confirmed these deficiencies, with residents being left unattended for long periods and not receiving necessary care. Despite efforts to address staffing shortages, such as offering incentives and contracting with staffing agencies, the facility continued to struggle with maintaining adequate staffing levels, impacting the quality of care provided to residents.
Neglect in Incontinence Care for Residents
Penalty
Summary
The facility failed to ensure that residents were free from neglect and mistreatment, specifically in providing timely incontinence care. Resident #19, who was severely cognitively impaired and dependent on staff for all activities of daily living, was observed to have not received incontinence care for over six hours. The resident was found with wet pants and a heavily saturated incontinence brief, indicating neglect in providing necessary care. Staff interviews revealed that the resident should have been checked and changed every two hours, but due to staffing issues, this was not done. Resident #40, also severely cognitively impaired and dependent on staff, was left without incontinence care for several hours, resulting in visibly wet pants and a saturated brief. Staff acknowledged the neglect, citing insufficient staffing as the reason for not providing timely care. The resident's care plan required regular checks and changes to prevent skin breakdown, but this was not adhered to, leading to neglectful care. Resident #20, with diagnoses including dementia and anxiety disorder, was similarly neglected in terms of incontinence care. The resident was left in a saturated brief for an extended period, with staff admitting they did not have time to provide the necessary care. Interviews with staff and management highlighted a lack of clear policy direction on the frequency of incontinence care, contributing to the neglect of residents' needs.
Ineffective QAPI Program Leads to Staffing Deficiency
Penalty
Summary
The facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program was in place, as evidenced by continued non-compliance with sufficient nursing staff. The administration was aware of the ongoing staffing issues, which were highlighted by concerns from staff, the resident council, and advocates. Despite having a QAPI plan that outlined a proactive approach to improving care and engagement, the facility did not maintain effective systems to address the deficiency of insufficient nursing staff, which was previously identified in a recertification survey. The facility's QAPI plan included goals to enhance resident care and develop a stable workforce by reducing turnover. However, the plan was ineffective in addressing the staffing deficiency, as evidenced by the facility's failure to meet minimum staffing numbers and provide adequate care, such as timely showers and meals. The facility's Continuous Quality Improvement Quarterly Reports and Resident Council minutes documented ongoing staffing concerns, but the facility's response, including adding new staff agencies, did not resolve the issue. Interviews with the Ombudsman, Acting Director of Nursing, Scheduler, Administrator, and Corporate Director of Skilled Nursing Facilities Administration confirmed awareness of the staffing issues. The Administrator acknowledged the deficiency and the challenges in meeting staffing requirements, despite efforts to communicate with corporate administration and access staffing agencies. The facility's inability to maintain sufficient nursing staff resulted in inadequate care for residents, as staff struggled to complete their duties due to low staffing levels.
Failure to Ensure Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least 8 consecutive hours, 7 days a week, as required by regulations, on three specific dates: 7/6/24, 7/19/24, and 7/21/24. The facility's assessment indicated a need for one RN to safely care for the residents, but on these dates, the required coverage was not met. On 7/6/24, two RNs were scheduled for overlapping 4-hour shifts, resulting in only 4 hours of coverage. On 7/19/24, the Director of Nursing (DON) was supposed to cover but was unavailable, and on 7/21/24, no RN was available. The facility did not have a waiver for these lapses in coverage. Interviews with the facility staff revealed awareness of the deficiency. Scheduler #1 acknowledged the lack of RN coverage and stated that both the DON and Administrator were informed but unable to secure coverage. The Acting DON confirmed awareness of the issue and mentioned attempts to find coverage, including contacting corporate for a float RN. The Administrator also acknowledged the deficiency, stating that corporate was unable to provide an RN for the affected days, and emphasized the importance of having an RN for resident assessments and care that LPNs could not perform.
Failure to Resolve Grievances for Missing Personal Property
Penalty
Summary
The facility failed to promptly resolve grievances related to missing personal property for two residents, as identified during an Extended Recertification survey. Resident #25, who was cognitively intact and had diagnoses including diabetes mellitus type II and chronic obstructive pulmonary disease, reported missing clothing items that were gifts received for Christmas. Despite notifying the nursing staff and the Social Worker designated as the Grievance Officer, no grievance form was filed, and there was no follow-up or resolution. The Social Worker acknowledged awareness of the missing items and sent emails to staff but did not pursue further action or reimbursement. Similarly, Resident #45, also cognitively intact with diagnoses including diabetes mellitus type II and osteomyelitis, reported missing a razor and beard/nose hair trimmer after a room change. The resident informed the nursing staff and the Social Work Department Director, who failed to file a grievance or follow up on the matter. The Social Work Department Director admitted to sending an email regarding the missing items but did not complete the grievance process or inform the Administrator. The facility's grievance policy requires grievances to be filed and resolved within five business days, but this was not adhered to in these cases. The Administrator was unaware of the missing items for both residents and stated that the grievance process should have been followed. Additionally, there was no evidence of a personal item list for Resident #45 upon admission, and the facility lacked a process to log personal property items on admission, contributing to the deficiency.
Deficiencies in Resident Care for Nutrition and Grooming
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living for two residents, leading to deficiencies in nutrition and grooming. Resident #29, who had diagnoses including Parkinson's disease and dysphagia, required limited assistance with eating and was on aspiration precautions. Despite these needs, staff did not provide the required assistance during meals, leaving the resident to eat alone and unsupervised. Observations showed that Resident #29 struggled to eat independently, consuming only 50% of their meals, and staff failed to check on or assist the resident as needed. Resident #63, who had severe cognitive impairment and was dependent on staff for personal hygiene, was observed with facial hair that was not removed during morning care. Despite being dependent on staff for grooming, the certified nurse aides did not offer or attempt to remove the facial hair, which was identified as a dignity concern by the nursing staff. Interviews with staff confirmed that facial hair removal should have been part of the resident's morning care routine, but it was neglected. The facility's failure to adhere to care plans and provide necessary assistance for these residents highlights deficiencies in maintaining residents' dignity and nutritional needs. Staff interviews revealed a lack of adherence to established protocols for assisting residents with eating and grooming, which are critical for their well-being and dignity. The facility's policies and procedures were not followed, resulting in inadequate care for these residents.
Failure to Act on Pharmacist's Medication Recommendations
Penalty
Summary
The facility failed to ensure that the pharmacist's recommendations for medication regimen reviews were properly addressed and documented by the attending physician, medical director, and director of nursing. Specifically, the pharmacist's recommendations for gradual dose reductions (GDR) and discontinuation of medications for Resident #19 were not consistently acted upon or documented with a rationale. The facility's policy required that any irregularities identified by the pharmacist be reported and acted upon, with the attending physician documenting the review and actions taken in the medical record. Resident #19, who had diagnoses including Alzheimer's disease, delirium, and cognitive communication deficit, was on psychotropic medications such as Zyprexa (olanzapine), Lexapro (escitalopram), and Trazodone. The pharmacy consultant recommended a GDR for Trazodone and olanzapine in April 2024, and a discontinuation of escitalopram in June 2024. However, the recommendations were not consistently followed or documented. Nurse Practitioner #1 agreed to reduce Trazodone but did not document a rationale for disagreeing with the reduction of olanzapine. Similarly, there was a conflict between the Physician Assistant and Nurse Practitioner regarding the discontinuation of escitalopram, which was not resolved, leading to the resident continuing on the medication. Interviews with staff revealed a lack of clarity and communication regarding the pharmacy consultant's recommendations. Licensed Practical Nurse #1 and the Acting Director of Nursing were unsure of the process and expected the nursing staff to seek clarification from medical providers. The Pharmacy Consultant noted inconsistencies in receiving addressed recommendations and expected documentation from providers when recommendations were declined. The Registered Nurse Unit Manager also highlighted the need for providers to document explanations when disagreeing with recommendations. This lack of communication and documentation led to the deficiency in ensuring proper medication management for Resident #19.
Deficiency in Daily Nursing Staff Information Posting
Penalty
Summary
The facility failed to ensure that the nursing staff information was posted daily with the required details during the Extended Recertification Survey. Specifically, the facility did not complete the forms to include the resident census and the actual hours worked by nursing staff, including Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides. Observations on multiple occasions revealed that the posted reports were either outdated or incomplete, lacking essential information such as the resident census and actual hours worked. Interviews with staff members revealed a lack of understanding and training regarding the completion and purpose of the daily staffing sheets. Scheduler #1, responsible for filling out the reports, was unaware of the need to update the forms when there were staff call-offs and did not receive formal training on how to complete them. The Acting Director of Nursing acknowledged that the staffing sheets were supposed to be updated every shift to reflect the actual staff present in the building but was unsure who was currently responsible for this task. This deficiency was found to be in violation of 10 NYCRR 415.13.
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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 Gerry
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Green Rehab & Skilled Nursing | 8.9 mi | ★★★★★ | 18 | 0 |
| Heritage Park Rehab & Skilled Nursing | 11 mi | ★★★★★ | 1 | 0 |
| Dunkirk Rehabilitation & Nursing Center | 16.3 mi | ★★★★★ | 0 | 0 |
| Chautauqua Nursing And Rehabilitation Center | 16.4 mi | ★★★★★ | 0 | 0 |
| Absolut Ctr For Nursing & Rehab Westfield L L C | 16.6 mi | — | 0 | 0 |
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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.