Heritage Green: COVID Vaccine Given Despite Refusal - NY
The error occurred September 26, 2024 at Heritage Green Rehab & Skilled Nursing, where Resident #1 — diagnosed with dementia, depression and hypertension but assessed as cognitively intact — had explicitly declined the vaccination on an undated consent form.
Licensed Practical Nurse #1 told investigators during an August 13, 2025 telephone interview that she "did not check Resident #1's wristband, to ensure correct, prior to administering the COVID-19 vaccination."
The facility's own medication administration policy, reviewed December 9, 2024, required staff to "check the resident wristband or bracelet or badge before administering the medication to make accurate resident identification."
A day after the vaccination, Licensed Practical Nurse #2 documented in an interdisciplinary note that the resident had received the shot in the right arm, noting "small red dot, slightly swollen and tender."
The facility filed a medication error report on September 26, stating that Licensed Practical Nurse #1 had "failed to follow resident's rights of medication administration when they failed to identify the correct resident."
Registered Nurse #1, who serves as the facility's infection preventionist, told investigators she was responsible for providing education and obtaining consent or declination forms for COVID-19 vaccinations. She acknowledged that "identifying the correct resident was one of the basic medication administration rights."
"Resident #1 received the COVID-19 vaccination, after signing a declination, which was a violation of Resident #1's rights," she said during the August 13 interview.
The facility's standing order policy for COVID-19, influenza and pneumococcal vaccines, revised January 6, 2024, stated that all residents would be screened upon admission to evaluate their immunization status. The policy required that "consent or declination of the COVID-19 vaccination will be obtained within seven (7) days of admission and documented in the medical record."
The policy also specified that "residents or responsible parties have the right to refuse any vaccination at any time, education and refusals will be documented in the medical record."
Director of Nursing confirmed the violation during an August 13 interview, stating that "Resident #1 received the COVID-19 vaccination in error. Licensed Practical Nurse #1 did not verify the correct resident prior to the administration of the vaccination."
She acknowledged that "the administration of the COVID-19 vaccination to Resident #1 violated their rights because the resident had signed a declination not to receive the vaccine."
The inspection, conducted as part of complaint investigation NY00364661-530180, found the facility failed to honor the resident's right to refuse treatment. Federal inspectors reviewed six residents' immunization records and found this single violation affecting one patient.
The error occurred despite multiple safeguards built into the facility's policies. Beyond the identification verification requirement, the consent process was designed to document each resident's decision about vaccination within a week of admission.
Resident #1's cognitive assessment from September 24, 2024 — conducted through the federally required Minimum Data Set evaluation tool — showed the resident was "cognitively intact," meaning they had the mental capacity to make their own medical decisions.
The violation represents what federal regulators classify as "minimal harm or potential for actual harm" affecting "few" residents. However, it strikes at a fundamental principle of nursing home care: the right of residents to make their own medical decisions and have those choices respected by staff.
The facility's infection preventionist, who obtains vaccination consents and declinations as part of her regular duties, recognized the severity of the error. Her acknowledgment that proper resident identification represents "one of the basic medication administration rights" underscores how fundamental the mistake was.
Licensed Practical Nurse #1's admission that she failed to check the resident's identification before giving the shot reveals a breakdown in the most basic safety protocol for medication administration — ensuring the right patient receives the right treatment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heritage Green Rehab & Skilled Nursing from 2025-08-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
HERITAGE GREEN REHAB & SKILLED NURSING in GREENHURST, NY was cited for violations during a health inspection on August 15, 2025.
Federal inspectors reviewed six residents' immunization records and found this single violation affecting one patient.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.