Heritage Green Rehab & Skilled Nursing

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Based on interview and record review conducted during a Complaint investigation (#NY00364661-530180),

the facility did not ensure that a resident has the right to refuse treatment for one (1) (Resident #1) of six (6) residents reviewed for immunizations. Specifically, Resident #1 was administered the COVID-19 vaccine without consent.The finding is:The policy and procedure titled Standing Order for Provision of Influenza, Pneumococcal, and COVID-19 Vaccine, revised 01/06/2024 documented all residents will be screened upon admission to the facility to evaluate COVID-19 immunization status. Consent or declination of the COVID-19 vaccination will be obtained within seven (7) days of admission and documented in the medical record. Residents or responsible parties have the right to refuse any vaccination at any time, education and refusals will be documented in the medical record.The policy and procedure titled Medication Administration revision/reviewed dated 12/09/2024 documented to check the resident wristband or bracelet or badge before administering the medication to make accurate resident identification.Resident #1 had diagnoses that included dementia, depression, and hypertension. The Minimum Data Set (a resident assessment tool) dated 09/24/2024 documented the resident was cognitively intact.The undated COVID-19 Booster Immunization Screening and Consent Form, signed by Resident #1, documented the resident declined to receive the vaccine.The Interdisciplinary Note dated 09/27/2024 at 2:42 PM authored by Licensed Practical Nurse #2 documented vaccination was given to right arm, small red dot, slightly swollen and tender.The Medication Error Report dated 09/26/2024 documented Licensed Practical Nurse #1 failed to follow resident's rights of medication administration when they failed to identify the correct resident.During a telephone interview on 08/13/2025 at 10:08 AM, Licensed Practical Nurse #1 stated they did not check Resident #1's wristband, to ensure correct, prior to administering the COVID-19 vaccination.During a telephone interview on 08/13/2025 at 12:02 PM, Registered Nurse #1 Infection Preventionist stated they provide the education and obtain consents/declinations for the COVID-19 vaccination. Identifying the correct resident was one of the basic medication administration rights.

Registered Nurse #1 Infection Preventionist stated Resident #1 received the COVID-19 vaccination, after signing a declination, which was a violation of Resident #1's rights.During an interview on 08/13/2025 at 12:18 PM, the Director of Nursing stated 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. 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.10 NYCRR 415.3(f)(1)(ii)

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Heritage Green Rehab & Skilled Nursing

3023 Route 430 Greenhurst, NY 14742

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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

have gotten a little better. Usually, they get into bed about 11:30 PM which they are fine with, sometimes 12:00 AM but it was better than 2:30 AM. Resident #2 stated all they ask of the staff was to give them a time frame as when they will be in to put them to bed. Sometimes they have to wait long to be changed or use the bed pan, about 45 minutes. Resident #2 stated they know the staff are busy due to the facility being short staffed. During an interview/observation on 08/15/2025 at 9:04 AM, Resident #3 stated they had waited over an hour that morning for assistance to the restroom because they were a two (2) assist with a mechanical lift and there were only two (2) Certified Nurse Aides on the unit, one (1) for each hall. Resident #3 stated they were unable to wait for staff assistance and soiled their brief making a mess in the bathroom when they were finally assisted. The toilet in the bathroom was observed to have feces on the seat.During

an interview/observation on 08/15/2025 at 9:11 AM, the call light system at the nurse's desk indicated Resident #5's call light had been ringing for eight (8) minutes. Resident #5 was observed in bed and appeared uncomfortable; a mechanical lift was observed in the room. Resident #5 stated they needed to have a bowel movement and did not want to have an accident, they stated one (1) staff member had brought the mechanical lift in the room but needed to find another staff member to assist. Staff were observed to enter the room at 9:29 AM to assist Resident #5.During an interview on 08/14/2025 at 9:53 AM, Licensed Practical Nurse #4 stated the unit they were assigned to normally had three (3) Certified Nurse Aides on the day shift and staff were unable to complete their assigned duties. Licensed Practical Nurse #4 stated residents may only be checked on once a shift if they don't put their call light on and showers were not given.During an interview on 08/14/2025, Certified Nurse Aide #1 stated they do their best with the staffing that was provided and residents that require assistance of two (2) staff members often have to wait longer than they should for assistance.During an interview on 08/14/2025 at 10:59 AM, Certified Nurse Aide #2 stated they were supposed to be on orientation but were given a full assignment and had not yet gotten to assist all the resident on their assignment.During an interview on 08/14/2025 at 11:03 AM, Certified Nurse Aide #3 stated the facility was often short staffed. Sometimes there were only two (2) Certified Nurse Aides on the day shift, at those times they go through the list of residents and ensure each resident gets changed at least once during the shift. Additionally, they stated they were unable to complete scheduled showers when working short staffed.During an interview on 08/15/2025 at 9:31 AM, Registered Nurse #2 Unit Manager stated there were times there were only two (2) Certified Nurse Aides

on the day shift and the necessities can get done at least once, but not everything can get done.During an

interview on 08/15/2025 at 10:23 AM, the Acting Administrator stated staffing had been difficult and challenging for the facility due to call offs. The facility had been working with minimum staffing since June and three (3) to four (4) days per week they have to strongly encourage staff to work over their scheduled shifts to ensure the residents were taken care of.10 NYCRR 415.13 (b)(1) (i-ii) (2)(ii)

Event ID:

Facility ID:

If continuation sheet