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
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
0.52
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.09
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.54
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.14
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.69
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.26
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,806
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.97
Composite VBP score used to determine payment impact.
Payment multiplier
0.9888
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.91
Baseline 18.77% · Performance 18.69% · Measure score 5.91 · Achievement 5.91 · Improvement 0
Healthcare-associated infections
3.73
Baseline 5.55% · Performance 6.72% · Measure score 3.73 · Achievement 3.73 · Improvement 0
Total nurse turnover
4.11
Baseline 52.94% · Performance 46.88% · Measure score 4.11 · Achievement 4.11 · Improvement 1.66
Adjusted total nurse staffing
0.24
Baseline 2.77 hours · Performance 2.99 hours · Measure score 0.24 · Achievement 0 · Improvement 0.24
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.29% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 66 · Observed rate 12.12% · Lower 95% interval 7.57% |
| Discharge to community | 41.39% |
50.57%
9.2 pts worse
|
No Different than the National Rate · Eligible stays 67 · Observed rate 35.82% · Lower 95% interval 30.25% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 17 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | 6.72% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 3.13% · Lower 95% interval 3.4% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 115 |
| Staff flu vaccination coverage | 72.92% |
42%
30.9 pts better
|
Numerator 105 · Denominator 144 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 · 4Q avg 96.2% |
| 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 · Q1 1.7% · Q2 4.3% · Q3 2.8% · Q4 2.9% · 4Q avg 2.8% · 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% · 4Q avg 0.0% |
| 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 · Q1 1.7% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% |
| 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 6.8% · Q2 11.1% · Q3 11.4% · Q4 8.8% · 4Q avg 9.2% |
| 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 · Q1 23.4% · Q2 20.6% · Q3 18.2% · Q4 13.8% · 4Q avg 19.6% · 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 | 20.2% |
15.1%
5.1 pts worse
|
16.3%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.6% · 4Q avg 20.2% · Used in QM five-star |
| 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 · Q1 17.8% · Q2 23.5% · Q3 9.5% · Q4 22.7% · 4Q avg 18.9% · Used in QM five-star |
| 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 · Q1 1.4% · Q2 2.1% · Q3 0.0% · Q4 1.7% · 4Q avg 1.3% · Used in QM five-star |
| 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 · Q1 8.3% · Q2 4.3% · Q3 2.8% · Q4 5.7% · 4Q avg 5.6% · Used in QM five-star |
| 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 · Q1 24.9% · Q2 25.7% · Q3 21.1% · Q4 18.5% · 4Q avg 23.1% |
| 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 · Q1 1.2% · Q2 3.4% · Q3 2.1% · Q4 3.4% · 4Q avg 2.4% · Used in QM five-star |
| 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 · Q1 76.2% · 4Q avg 70.6% |
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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