Cycle 1
Health 2024-03-01 · Fire 2024-03-01
6 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Jamestown, NY
Heritage Park Rehab & Skilled Nursing
2-star overall rating with 3-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
150 Prather Avenue, Jamestown, NY
(716) 488-1921
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
146
Certified beds
Average residents
123
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Heritage Ministries
Operator or chain grouping
Approved since
1967-01-01
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
0.33
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.27
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
2.29
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.02
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.01
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.35
CMS adjusted RN staffing hours
Adjusted total hours
2.42
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,259
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.46
Composite VBP score used to determine payment impact.
Payment multiplier
0.9877
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.24
Baseline 17.12% · Performance 17.61% · Measure score 8.24 · Achievement 8.24 · Improvement 0
Healthcare-associated infections
0.61
Baseline 4.61% · Performance 7.65% · Measure score 0.61 · Achievement 0.61 · Improvement 0
Total nurse turnover
4.53
Baseline 36.52% · Performance 45.16% · Measure score 4.53 · Achievement 4.53 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.27 hours · Performance 2.53 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.67% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 200 · Observed rate 8% · Lower 95% interval 6.98% |
| Discharge to community | 34.53% |
50.57%
16 pts worse
|
Worse than the National Rate · Eligible stays 216 · Observed rate 30.56% · Lower 95% interval 27.59% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 96.85% |
95.27%
1.6 pts better
|
Numerator 123 · Denominator 127 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 127 |
| Discharge self-care score | 39.8% |
53.69%
13.9 pts worse
|
Numerator 39 · Denominator 98 |
| Discharge mobility score | 51.02% |
50.94%
0.1 pts better
|
Numerator 50 · Denominator 98 |
| Pressure ulcers or injuries, new or worsened | 2.36% |
2.29%
0.1 pts worse
|
Numerator 3 · Denominator 127 · Adjusted rate 2.54% |
| Healthcare-associated infections requiring hospitalization | 7.65% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 115 · Observed rate 7.83% · Lower 95% interval 4.48% |
| Staff COVID-19 vaccination coverage | 0.56% |
8.2%
7.6 pts worse
|
Numerator 1 · Denominator 177 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 48.98% |
56.45%
7.5 pts worse
|
Numerator 48 · Denominator 98 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 26 · Denominator 26 |
| Transfer of health information to patient | 96% |
96.28%
0.3 pts worse
|
Numerator 48 · Denominator 50 |
| Resident COVID-19 vaccinations up to date | 37.14% |
25.2%
11.9 pts better
|
Numerator 26 · Denominator 70 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.7
0.8 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.0 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.3
0.5 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 1.0 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 84.9% |
91.2%
6.3 pts worse
|
93.4%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 94.3% · Q2 81.7% · Q3 85.0% · Q4 78.2% · 4Q avg 84.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.9% |
95.3%
3.4 pts worse
|
95.5%
3.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.3% |
3.0%
1.3 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.8% · Q3 4.7% · Q4 4.0% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
18.5%
17.4 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.1% · Q4 2.3% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 5.4% |
6.1%
0.7 pts better
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 4.0% · Q3 3.9% · Q4 5.1% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.2% |
13.5%
4.3 pts better
|
19.6%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 7.8% · Q3 12.4% · Q4 9.0% · 4Q avg 9.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.6% |
14.8%
1.8 pts worse
|
16.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 18.6% · Q3 15.5% · Q4 15.4% · 4Q avg 16.6% · 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 | 16.1% |
15.1%
1 pts worse
|
16.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 23.2% · Q3 16.6% · Q4 10.8% · 4Q avg 16.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.7% |
15.5%
2.2 pts worse
|
14.9%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 16.7% · Q3 18.5% · Q4 18.7% · 4Q avg 17.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.2% |
0.6%
2.6 pts worse
|
1.0%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 2.5% · Q3 3.6% · Q4 3.0% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.1% |
1.4%
3.7 pts worse
|
1.7%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 5.8% · Q3 5.7% · Q4 5.9% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.4% |
20.8%
12.4 pts better
|
19.8%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 10.8% · Q3 7.7% · Q4 9.7% · 4Q avg 8.4% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
6.9%
1 pts better
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 6.7% · Q3 4.3% · Q4 7.7% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 58.6% |
76.7%
18.1 pts worse
|
81.7%
23.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 62.4% · Q2 53.5% · Q3 55.1% · Q4 63.3% · 4Q avg 58.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.2% |
9.7%
3.5 pts better
|
12.0%
5.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.2% · Observed 6.0% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.2%
0.2 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 1.4% · Q4 1.4% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 55.7% |
78.8%
23.1 pts worse
|
79.7%
24 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 55.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.9% |
20.6%
5.7 pts better
|
23.9%
9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.9% · Observed 13.7% · Expected 21.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-05-06 · Fire 2022-05-06
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2019-04-26 · Fire 2019-04-26
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-03-01
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-04-26
E · Potential for more than minimal harm
2024-03-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-26
E · Potential for more than minimal harm
2024-03-01
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-04-26
E · Potential for more than minimal harm
2024-03-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-26
E · Potential for more than minimal harm
2022-05-06
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 2022-06-30
D · Potential for more than minimal harm
2022-05-06
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-06-30
D · Potential for more than minimal harm
2022-05-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-06-30
D · Potential for more than minimal harm
2019-04-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-06-26
C · Minimal harm
2019-04-26
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2019-06-24
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-09-12
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 2025-11-10
E · Potential for more than minimal harm
2024-03-01
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 2024-04-26
E · Potential for more than minimal harm
2024-03-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-03-01
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-03-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-26
C · Minimal harm
2024-03-01
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2024-04-26
D · Potential for more than minimal harm
2022-05-06
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-06-30
E · Potential for more than minimal harm
2019-04-26
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-06-24
D · Potential for more than minimal harm
2019-04-26
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2019-06-24
D · Potential for more than minimal harm
2019-04-26
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 2019-06-24
Penalties and ownership
What sits behind the stars
Ownership
Burkhouse, Jessica
Operational/Managerial Control · Individual
Fernandez, Gregory
Corporate Director · Individual
Haglund, Lisa
Operational/Managerial Control · Individual
Haglund, Lisa
Corporate Officer · Individual
Noll, Pamela
Corporate Director · Individual
Persia, Albert
Operational/Managerial Control · Individual
Spanos, Mary Ann
Corporate Director · Individual
Stark, Peter
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Heritage Green Rehab & Skilled Nursing
Greenhurst, NY
1-star overall rating with 2-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Heritage Village Rehab And Skilled Nursing Inc.
Gerry, NY
2-star overall rating with 2-star inspections with abuse icon flag with 8 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Rouse Warren County Home
Youngsville, PA
2-star overall rating with 3-star inspections with $22,967 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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