Heritage Village Rehab And Skilled Nursing Inc.

F-F600 Free from abuse and neglect scope and severity F

Refer to

F-F725 Sufficient Nursing Staff scope and severity F

Refer to

F-F727 Registered 8 hours/7 days/week scope and severity E

Review of Recertification Survey Statement of Deficiencies (form 2567) issued by the New York State Department of Health with an exit date of 8/12/22 revealed the facility was cited at F-725 for the lack of sufficient nurse staffing to meet the care needs of the residents. The facilities corrective action plan included adequate staff will be provided to ensure residents will be served and fed in an appropriate amount of time. Call bell wait times will be adequate, showers/baths will be provided. Trend analysis data will be reviewed by QAPI trends or issues will be discussed and recommendations for improvement will be made as needed.

Review of the facility's Continuous Quality Improvement Quarterly Report agenda dated July 25, 2023; October 31,2023; and February 6, 2024, documented that turnover statistic were review at the meeting.

Review of the Facility Continuous Quality Improvement Quarterly Report agenda date April 23,2024 documented that turnover statistics and current nursing coverage was reviewed at the meeting.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 28 335353 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335353 B. Wing 08/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Heritage Village Rehab and Skilled Nursing Inc. 4570 Route 60 Gerry, NY 14740

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Review of the Resident Council minutes on 7/29/24 revealed staffing concerns were discussed in April 2024. May 2024 minutes residents complained of not getting their showers. The facility response was to add new Level of Harm - Minimal harm or staff agencies to their staff pool. In June 2024 they discussed the new agency staff during the meeting, but potential for actual harm the residents' responses were not documented.

Residents Affected - Many During an interview on 7/30/24 at 11:36 AM, the Ombudsman stated the residents had concerns with staffing at the facility. They stated the Administrator was aware of the residents' concerns.

During an interview on 8/2/24 at 11:07 AM, the Acting Director of Nursing, stated they were aware the facility was not meeting their minimum staffing numbers and they did not feel that staff could get their work done, including incontinence care, and serving meals. They stated the Administrator and Corporate were aware

they were not meeting their minimum staffing numbers. The Acting Director of Nursing also stated they were aware the facility had days where there was no Registered Nurse in the building for the required 8 consecutive hours.

During an interview on 8/1/24 at 11:34 AM, Scheduler #1 stated the facility did not meet their minimum staffing numbers on several days. Scheduler #1 stated there were 5 agencies contracted, but currently only 1 was able to be used. Scheduler #1 stated the Director of Nursing, and the Administrator were both aware

they were not meeting their minimum staffing numbers.

During an interview on 8/2/24 at 12:09 PM, the Administrator stated they were aware that there were days

the facility did not have a Registered Nurse for the required 8 consecutive hours. They stated when they were notified that there was no Registered Nurse available, they notified Corporate and attempted to find coverage. They understood that it was essentially the Administrators responsibility to ensure safe nursing coverage in the facility. The Administrator stated they were aware they were not meeting their minimum staffing. The Administrator stated that staff had come to them and told them they could not get their work done because of low staffing.

During an interview on 8/2/24 at 1:07 PM, with the Acting Director of Nursing present, the Administrator stated that Quality Assurance Committee meets quarterly for a formal meeting and involves the interdisciplinary team members, the Medical Director, and a board member. The Administrator stated they were aware the facility had a cited deficiency for insufficient nursing staffing on the last recertification survey that involved the inability of staff to perform adequate care needs for the residents. The Administrator stated that had discussed as an interdisciplinary team about the need for more nurse staffing and developed interventions. The Administrator stated that they had communicated with cooperate administration about the lack of staff retention and were given more access to staffing agencies and staff incentives. The Administrator stated that the quality improvement plan was effective because it was brought out awareness that more nursing staff was needed. The Administrator stated they strive to meet the facilities minimal staffing numbers but due to call offs it is too hard to react on a short-term basis. The Administrator added the facility could always use more staff.

During an interview on 8/2/24 at 1:49 PM, the Corporate Director of Skilled Nursing Facilities Administration stated they were aware the facility was not meeting their minimum nurse staffing numbers. They felt the staff could get their work done with the numbers they had, but that was not their goal.

10 NYCRR 415.27 (c)(2)(3)(v)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 28 335353