Heritage Green Rehab & Skilled Nursing
3023 Route 430, Greenhurst, NY 14742 · Chautauqua County · 134 certified beds · avg 116 residents/day · certified since May 14, 1992
Part of chain: HERITAGE MINISTRIES (3 facilities, chain avg rating 2.0★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Dec 7, 2021 · F-0725
The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care.
Why it matters: Understaffing means longer waits for help, missed care, and higher risk of falls and other harm.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Jan 31, 2022 (Deficient, Provider has date of correction)
All citations in the current public record (16)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Feb 27, 2026 | F · Potential for harm, facility-wide | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Feb 27, 2026 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · from a complaint |
| Feb 27, 2026 | E · Potential for harm, repeated | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Feb 27, 2026 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Feb 27, 2026 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 27, 2026 | D · Potential for harm, one-off | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Feb 27, 2026 | C · Minimal risk, facility-wide | The facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman. |
| Aug 15, 2025 | F · Potential for harm, facility-wide | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Aug 15, 2025 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. · from a complaint |
| Feb 1, 2024 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Feb 1, 2024 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Feb 1, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Feb 1, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Feb 1, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD). |
| Dec 7, 2021 | ▲ K · Immediate jeopardy, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Dec 7, 2021 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (5 → 7).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 2 | 1 | K ▲ |
| 2024 | 5 | 0 | D |
| 2025 | 2 | 0 | F |
| 2026 | 7 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | New York avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.61 | 3.58 | 3.95 | bottom 6% in New York; bottom 5% in the U.S. |
| Registered Nurse hours | 0.34 | 0.68 | 0.69 | bottom 8% in New York; bottom 14% in the U.S. |
| Weekend total nurse staffing | 2.31 | 3.13 | 3.50 | bottom 6% in New York; bottom 5% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.14 | 0.48 | 0.48 | bottom 3% in New York; bottom 4% in the U.S. |
| Total nursing staff turnover (%) | 51.1 | 40.3 | 45.8 | bottom 23% in New York; bottom 34% in the U.S. |
| RN turnover (%) | 30.0 | 39.8 | 42.9 | top 29% in New York; top 29% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.42, RN 0.32, weekend 2.14. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: 3/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Heritage Ministries Charitable Care Network INC. | Organization | 5% or Greater Direct Ownership Interest | 100% | 08/11/2008 |
| Burkhouse, Jessica | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/14/2014 |
| Burkhouse, Jessica | Individual | ADP of the SNF | NOT APPLICABLE | 06/14/2014 |
| Digregorio, Robin | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/25/2024 |
| Digregorio, Robin | Individual | ADP of the SNF | NOT APPLICABLE | 12/05/2025 |
| Fernandez, Gregory | Individual | Corporate Director | NOT APPLICABLE | 11/25/2024 |
| Fernandez, Gregory | Individual | Trustee of the SNF | NOT APPLICABLE | 11/25/2024 |
| Haglund, Lisa | Individual | Corporate Officer | NOT APPLICABLE | 05/11/2020 |
| Haglund, Lisa | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/25/2024 |
| Haglund, Lisa | Individual | ADP of the SNF | NOT APPLICABLE | 05/11/2020 |
| Noll, Pamela | Individual | Corporate Director | NOT APPLICABLE | 11/25/2024 |
| Noll, Pamela | Individual | Trustee of the SNF | NOT APPLICABLE | 11/25/2024 |
| Persia, Albert | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/24/2023 |
| Persia, Albert | Individual | ADP of the SNF | NOT APPLICABLE | 07/24/2023 |
| Spanos, Mary Ann | Individual | Corporate Director | NOT APPLICABLE | 11/25/2024 |
| Spanos, Mary Ann | Individual | Trustee of the SNF | NOT APPLICABLE | 11/25/2024 |
| Stark, Peter | Individual | Corporate Director | NOT APPLICABLE | 11/25/2024 |
| Stark, Peter | Individual | Trustee of the SNF | NOT APPLICABLE | 11/25/2024 |
| Wilcox, Mark | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/25/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
- "How many hours a day is a registered nurse physically in the building, including weekends?"
- "What alternatives do you try before using bed rails, and how do you involve families in that decision?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Could I join residents for a meal to see the food quality and temperature for myself?"
- "Where do you post your latest state inspection results and the ombudsman's contact information?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Heritage Park Rehab & Skilled Nursing | 4.3 mi | Jamestown, NY | ★☆☆☆☆ | 1/5 | |
| Rouse Warren County Home | 19.3 mi | Youngsville, PA | ★☆☆☆☆ | 2/5 | abuse |
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Facility data as of CMS processing date 2026-08-01. CCN 335721.