Greenhurst, NY

Heritage Green Rehab & Skilled Nursing

1-star overall rating with 2-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

3023 Route 430, Greenhurst, NY

(716) 483-5000

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

134

Certified beds

Average residents

108

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Heritage Ministries

Operator or chain grouping

Approved since

1992-05-14

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

4 facilities

Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.34

Registered nurse staffing · state 0.70 · national 0.68

LPN hours / resident day

0.88

Licensed practical nurse staffing · state 0.78 · national 0.87

Aide hours / resident day

1.62

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

2.84

All reported nurse hours · state 3.65 · national 3.89

Licensed hours

1.22

RN + LPN hours · state 1.47 · national 1.54

Weekend hours

2.40

Weekend nurse staffing · state 3.16 · national 3.43

Weekend RN hours

0.17

Weekend registered nurse coverage · state 0.47 · national 0.47

Physical therapist

0.11

Reported PT staffing · state 0.11 · national 0.07

Adjusted RN hours

0.35

CMS adjusted RN staffing hours

Adjusted total hours

2.95

CMS adjusted total nurse staffing hours

Case-mix index

1.32

Higher values indicate more complex resident acuity

RN turnover

25%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

42%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

2,470

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

49.60

Composite VBP score used to determine payment impact.

Payment multiplier

1.0036

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.46

Baseline 20.21% · Performance 19.37% · Measure score 4.46 · Achievement 4.46 · Improvement 2.16

Healthcare-associated infections

8.88

Baseline 4.79% · Performance 5.18% · Measure score 8.88 · Achievement 8.88 · Improvement 0

Total nurse turnover

6.5

Baseline 45.78% · Performance 37.11% · Measure score 6.5 · Achievement 6.5 · Improvement 3.64

Adjusted total nurse staffing

0

Baseline 2.93 hours · Performance 2.83 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.88%	10.72% 0.2 pts worse	No Different than the National Rate · Eligible stays 161 · Observed rate 10.56% · Lower 95% interval 8.12%
Discharge to community	44.24%	50.57% 6.3 pts worse	No Different than the National Rate · Eligible stays 139 · Observed rate 41.01% · Lower 95% interval 35.76%
Medicare spending per beneficiary	0.96	1.02 0.1 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 90 · Denominator 90
Falls with major injury	2.22%	0.77% 1.5 pts worse	Numerator 2 · Denominator 90
Discharge self-care score	56.06%	53.69% 2.4 pts better	Numerator 37 · Denominator 66
Discharge mobility score	68.18%	50.94% 17.2 pts better	Numerator 45 · Denominator 66
Pressure ulcers or injuries, new or worsened	6.67%	2.29% 4.4 pts worse	Numerator 6 · Denominator 90 · Adjusted rate 7.81%
Healthcare-associated infections requiring hospitalization	5.18%	7.12% 1.9 pts better	No Different than the National Rate · Eligible stays 78 · Observed rate 0% · Lower 95% interval 2.43%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 168
Staff flu vaccination coverage	82.74%	42% 40.7 pts better	Numerator 163 · Denominator 197
Discharge function score	68.18%	56.45% 11.7 pts better	Numerator 45 · Denominator 66
Transfer of health information to provider	95.65%	95.95% 0.3 pts worse	Numerator 22 · Denominator 23
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 45 · Denominator 45
Resident COVID-19 vaccinations up to date	36.73%	25.2% 11.5 pts better	Numerator 18 · Denominator 49

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	0.6	1.7 1.1 pts better	1.9 1.3 pts better	Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.4 · Expected 1.3 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.6	1.3 0.3 pts worse	1.8 0.2 pts better	Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.3 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	71.9%	91.2% 19.3 pts worse	93.4% 21.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 77.5% · Q2 74.3% · Q3 67.4% · Q4 67.4% · 4Q avg 71.9%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	94.6%	95.3% 0.7 pts worse	95.5% 0.9 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 94.6%
Percentage of long-stay residents experiencing one or more falls with major injury	2.9%	3.0% 0.1 pts better	3.3% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.0% · Q3 3.3% · Q4 3.4% · 4Q avg 2.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	18.5% 18.5 pts better	11.4% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents who lose too much weight	9.1%	6.1% 3 pts worse	5.4% 3.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 8.1% · Q3 4.5% · Q4 9.3% · 4Q avg 9.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	9.9%	13.5% 3.6 pts better	19.6% 9.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 11.1% · Q3 9.0% · Q4 7.0% · 4Q avg 9.9%
Percentage of long-stay residents who received an antipsychotic medication	24.5%	14.8% 9.7 pts worse	16.7% 7.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 23.2% · Q3 24.7% · Q4 28.0% · 4Q avg 24.5% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	32.9%	15.1% 17.8 pts worse	16.3% 16.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 36.1% · Q2 37.4% · Q3 38.5% · 4Q avg 32.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	21.1%	15.5% 5.6 pts worse	14.9% 6.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 31.1% · Q3 17.1% · Q4 7.7% · 4Q avg 21.1% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.1%	0.6% 0.5 pts worse	1.0% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.7% · Q3 0.8% · Q4 2.1% · 4Q avg 1.1% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.3%	1.4% 1.1 pts better	1.7% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	22.4%	20.8% 1.6 pts worse	19.8% 2.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.1% · Q2 27.4% · Q3 19.8% · Q4 19.7% · 4Q avg 22.4%
Percentage of long-stay residents with pressure ulcers	8.2%	6.9% 1.3 pts worse	5.1% 3.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 9.5% · Q3 6.6% · Q4 5.8% · 4Q avg 8.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	46.8%	76.7% 29.9 pts worse	81.7% 34.9 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 37.9% · Q2 61.6% · Q3 52.9% · Q4 37.2% · 4Q avg 46.8%
Percentage of short-stay residents who had an outpatient emergency department visit	13.4%	9.7% 3.7 pts worse	12.0% 1.4 pts worse	Short Stay · 20240701-20250630 · Adjusted 13.4% · Observed 12.8% · Expected 10.6% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.3%	1.2% 0.9 pts better	1.6% 1.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	68.0%	78.8% 10.8 pts worse	79.7% 11.7 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 68.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	20.6%	20.6% About the same	23.9% 3.3 pts better	Short Stay · 20240701-20250630 · Adjusted 20.6% · Observed 20.2% · Expected 23.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-02-01 · Fire 2024-02-01

7 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2021-12-07 · Fire 2021-12-07

2 health deficiencies

Top issue: Nursing and Physician Services (1 deficiency)

3 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2019-03-29 · Fire 2019-03-29

6 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2024-02-01

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2024-03-31

E · Potential for more than minimal harm 2024-02-01

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-03-15

E · Potential for more than minimal harm 2024-02-01

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-03-31

E · Potential for more than minimal harm 2024-02-01

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-03-31

E · Potential for more than minimal harm 2021-12-07

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2022-01-04

E · Potential for more than minimal harm 2021-12-07

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-01-03

E · Potential for more than minimal harm 2021-12-07

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2022-01-04

E · Potential for more than minimal harm 2019-03-29

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2019-05-28

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-08-15

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2025-10-13

D · Potential for more than minimal harm 2025-08-15

F578 · Resident Rights Deficiencies

Health

Honor 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.

Corrected 2025-10-13

D · Potential for more than minimal harm 2024-02-01

F578 · Resident Rights Deficiencies

Health

Honor 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.

Corrected 2024-03-31

D · Potential for more than minimal harm 2024-02-01

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2024-03-31

D · Potential for more than minimal harm 2024-02-01

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-03-31

D · Potential for more than minimal harm 2024-02-01

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-03-31

D · Potential for more than minimal harm 2024-02-01

F742 · Quality of Life and Care Deficiencies

Health

Provide 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.

Corrected 2024-03-31

K · Immediate jeopardy 2021-12-07

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2022-01-31

D · Potential for more than minimal harm 2021-12-07