Cycle 1
Health 2024-08-02 · Fire 2024-08-02
8 health deficiencies
Top issue: Nursing and Physician Services (3 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Gerry, NY
Heritage Village Rehab And Skilled Nursing Inc.
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
4570 Route 60, Gerry, NY
(716) 985-4612
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
35
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Heritage Ministries
Operator or chain grouping
Approved since
1972-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.52
Registered nurse staffing
LPN hours / resident day
1.09
Licensed practical nurse staffing
Aide hours / resident day
1.54
Nurse aide staffing
Weekend hours
2.69
Weekend nurse staffing
RN turnover
50%
Annual RN turnover
Total nurse turnover
63%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.2%
8.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.2% |
95.3%
0.9 pts better
|
95.5%
0.7 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.0%
0.2 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents who lose too much weight | 1.2% |
6.1%
4.9 pts better
|
5.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents who received an antipsychotic medication | 19.6% |
14.8%
4.8 pts worse
|
16.7%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.2% |
15.1%
5.1 pts worse
|
16.3%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.9% |
15.5%
3.4 pts worse
|
14.9%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.6%
0.7 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 5.6% |
1.4%
4.2 pts worse
|
1.7%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.1% |
20.8%
2.3 pts worse
|
19.8%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
6.9%
4.5 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 70.6% |
76.7%
6.1 pts worse
|
81.7%
11.1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-12 · Fire 2022-08-12
4 health deficiencies
Top issue: Administration (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2019-09-23 · Fire 2019-09-23
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-08-02
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-02
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-02
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-02
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-30
E · Potential for more than minimal harm
2022-08-12
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 2022-08-13
E · Potential for more than minimal harm
2022-08-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-08-29
E · Potential for more than minimal harm
2022-08-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-30
E · Potential for more than minimal harm
2022-08-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-09-02
E · Potential for more than minimal harm
2022-08-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-08-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-08-13
D · Potential for more than minimal harm
2019-09-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-11-11
D · Potential for more than minimal harm
2019-09-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-11-11
D · Potential for more than minimal harm
2019-09-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-11-11
D · Potential for more than minimal harm
2019-09-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-11-11
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-08-02
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-02
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 2024-09-30
F · Potential for more than minimal harm
2024-08-02
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-02
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-02
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-02
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 2024-09-30
D · Potential for more than minimal harm
2024-08-02
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-09-30
B · Minimal harm
2024-08-02
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-09-30
E · Potential for more than minimal harm
2022-08-12
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 2022-10-12
D · Potential for more than minimal harm
2022-08-12
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-10-12
D · Potential for more than minimal harm
2022-08-12
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-10-12
C · Minimal harm
2022-08-12
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2022-10-12
D · Potential for more than minimal harm
2019-09-23
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 2019-11-11
D · Potential for more than minimal harm
2019-09-23
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-11-11
B · Minimal harm
2019-09-23
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2019-11-11
Penalties and ownership
What sits behind the stars
Ownership
Heritage Ministries Charitable Care Network Inc.
5% Or Greater Direct Ownership Interest · Organization
Boswell, Matthew
Operational/Managerial Control · Individual
Boswell, Matthew
Corporate Director · Individual
Fernandez, Gregory
Corporate Director · Individual
Noll, Pamela
Corporate Director · Individual
Otterbein, Christopher
Operational/Managerial Control · Individual
Otterbein, Christopher
Corporate Officer · Individual
Persia, Albert
Operational/Managerial Control · Individual
Persia, Albert
Corporate Officer · 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 Park Rehab & Skilled Nursing
Jamestown, NY
2-star overall rating with 3-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Dunkirk Rehabilitation & Nursing Center
Dunkirk, NY
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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