Warsaw, NY

Wyoming County Community Hospital S N F

5-star overall rating with 4-star inspections with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle

400 North Main Street, Warsaw, NY

(585) 786-2233

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

138

Certified beds

Average residents

134

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1967-01-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Hospital-based

Yes

CMS reports the provider resides in a hospital

Staffing

Hours and turnover

RN hours / resident day

0.43

Registered nurse staffing · state 0.70 · national 0.68

LPN hours / resident day

1.29

Licensed practical nurse staffing · state 0.78 · national 0.87

Aide hours / resident day

2.34

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

4.06

All reported nurse hours · state 3.65 · national 3.89

Licensed hours

1.72

RN + LPN hours · state 1.47 · national 1.54

Weekend hours

3.38

Weekend nurse staffing · state 3.16 · national 3.43

Weekend RN hours

0.20

Weekend registered nurse coverage · state 0.47 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.11 · national 0.07

Adjusted RN hours

0.48

CMS adjusted RN staffing hours

Adjusted total hours

4.50

CMS adjusted total nurse staffing hours

Case-mix index

1.23

Higher values indicate more complex resident acuity

RN turnover

8%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

28%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

1,068

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

60.29

Composite VBP score used to determine payment impact.

Payment multiplier

1.0154

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

6.52

Baseline 19.21% · Performance 18.41% · Measure score 6.52 · Achievement 6.52 · Improvement 3.16

Healthcare-associated infections

5.56

Baseline 5.85% · Performance 6.17% · Measure score 5.56 · Achievement 5.56 · Improvement 0

Total nurse turnover

7.54

Baseline 38.64% · Performance 32.88% · Measure score 7.54 · Achievement 7.54 · Improvement 3.68

Adjusted total nurse staffing

4.50

Baseline 3.79 hours · Performance 4.36 hours · Measure score 4.50 · Achievement 4.50 · Improvement 2.37

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.5%	10.72% 1.2 pts better	No Different than the National Rate · Eligible stays 105 · Observed rate 6.67% · Lower 95% interval 6.62%
Discharge to community	46.88%	50.57% 3.7 pts worse	No Different than the National Rate · Eligible stays 97 · Observed rate 41.24% · Lower 95% interval 38.38%
Medicare spending per beneficiary	0.77	1.02 0.2 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 53 · Denominator 53
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 53
Discharge self-care score	34.78%	53.69% 18.9 pts worse	Numerator 16 · Denominator 46
Discharge mobility score	32.61%	50.94% 18.3 pts worse	Numerator 15 · Denominator 46
Pressure ulcers or injuries, new or worsened	1.89%	2.29% 0.4 pts better	Numerator 1 · Denominator 53 · Adjusted rate 1.9%
Healthcare-associated infections requiring hospitalization	6.17%	7.12% 1 pts better	No Different than the National Rate · Eligible stays 65 · Observed rate 3.08% · Lower 95% interval 3.21%
Staff COVID-19 vaccination coverage	3.74%	8.2% 4.5 pts worse	Numerator 7 · Denominator 187
Staff flu vaccination coverage	63.9%	42% 21.9 pts better	Numerator 177 · Denominator 277
Discharge function score	43.48%	56.45% 13 pts worse	Numerator 20 · Denominator 46
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	61.54%	25.2% 36.3 pts better	Numerator 16 · Denominator 26

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	0.9	1.7 0.8 pts better	1.9 1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.5 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.1	1.3 0.2 pts better	1.8 0.7 pts better	Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.6%	91.2% 8.4 pts better	93.4% 6.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.5% · 4Q avg 99.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	95.3% 4.7 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	6.1%	3.0% 3.1 pts worse	3.3% 2.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.6% · Q3 4.7% · Q4 9.1% · 4Q avg 6.1% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	5.8%	18.5% 12.7 pts better	11.4% 5.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 5.2% · Q3 4.9% · Q4 6.4% · 4Q avg 5.8%
Percentage of long-stay residents who lose too much weight	2.3%	6.1% 3.8 pts better	5.4% 3.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.7% · Q3 4.3% · Q4 1.6% · 4Q avg 2.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	14.9%	13.5% 1.4 pts worse	19.6% 4.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 16.7% · Q3 14.1% · Q4 14.4% · 4Q avg 14.9%
Percentage of long-stay residents who received an antipsychotic medication	13.1%	14.8% 1.7 pts better	16.7% 3.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.6% · Q2 12.1% · Q3 14.2% · Q4 13.2% · 4Q avg 13.1% · 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	10.4%	15.1% 4.7 pts better	16.3% 5.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 9.0% · Q3 8.8% · Q4 10.0% · 4Q avg 10.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	8.1%	15.5% 7.4 pts better	14.9% 6.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 6.2% · Q3 7.9% · Q4 7.8% · 4Q avg 8.1% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.6% 0.6 pts better	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% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.0%	1.4% 0.4 pts better	1.7% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.8% · Q3 0.8% · Q4 1.5% · 4Q avg 1.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	32.6%	20.8% 11.8 pts worse	19.8% 12.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 31.0% · Q2 34.9% · Q3 32.4% · Q4 32.0% · 4Q avg 32.6%
Percentage of long-stay residents with pressure ulcers	3.5%	6.9% 3.4 pts better	5.1% 1.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 5.0% · Q3 3.8% · Q4 3.4% · 4Q avg 3.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	89.4%	76.7% 12.7 pts better	81.7% 7.7 pts better	Short Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 93.1% · Q3 97.4% · Q4 64.1% · 4Q avg 89.4%
Percentage of short-stay residents who had an outpatient emergency department visit	3.3%	9.7% 6.4 pts better	12.0% 8.7 pts better	Short Stay · 20240701-20250630 · Adjusted 3.3% · Observed 3.0% · Expected 10.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.2%	1.2% 1 pts worse	1.6% 0.6 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.6% · Q3 0.0% · 4Q avg 2.2% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	98.3%	78.8% 19.5 pts better	79.7% 18.6 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 98.3%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	10.6%	20.6% 10 pts better	23.9% 13.3 pts better	Short Stay · 20240701-20250630 · Adjusted 10.6% · Observed 9.1% · Expected 20.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-03-01 · Fire 2024-03-01

4 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

7 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 2 Health 2022-03-11 · Fire 2022-03-11

3 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2019-02-12 · Fire 2019-02-12

9 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2024-03-01

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 2024-04-29

E · Potential for more than minimal harm 2024-03-01

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-04-29

E · Potential for more than minimal harm 2024-03-01

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-04-29

E · Potential for more than minimal harm 2024-03-01

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-04-29

E · Potential for more than minimal harm 2024-03-01

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-04-29

E · Potential for more than minimal harm 2024-03-01

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-04-29

D · Potential for more than minimal harm 2024-03-01

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2024-04-29

E · Potential for more than minimal harm 2022-03-11

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 2022-04-15

E · Potential for more than minimal harm 2022-03-11

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2022-04-15

D · Potential for more than minimal harm 2022-03-11

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2022-04-22

E · Potential for more than minimal harm 2019-02-12

K908 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.

Corrected 2019-04-08

E · Potential for more than minimal harm 2019-02-12

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2019-03-06

D · Potential for more than minimal harm 2019-02-12

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Corrected 2019-04-08

Inspection history

Recent health citations

D · Potential for more than minimal harm 2024-03-01

F578 · Resident Rights Deficiencies

Health

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.

Corrected 2024-04-29

D · Potential for more than minimal harm 2024-03-01

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 2024-04-29

D · Potential for more than minimal harm 2024-03-01

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 2024-04-29

D · Potential for more than minimal harm 2024-03-01

F700 · Quality of Life and Care Deficiencies

Health

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Corrected 2024-04-29

D · Potential for more than minimal harm 2023-06-14

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 2023-08-11

E · Potential for more than minimal harm 2022-03-11

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2022-04-15

D · Potential for more than minimal harm 2022-03-11

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 2022-04-29

D · Potential for more than minimal harm 2022-03-11

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2022-03-24

D · Potential for more than minimal harm 2019-02-12

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2019-04-08

D · Potential for more than minimal harm 2019-02-12

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2019-04-08

D · Potential for more than minimal harm 2019-02-12

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2019-04-08

D · Potential for more than minimal harm 2019-02-12

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2019-04-08

D · Potential for more than minimal harm 2019-02-12

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2019-04-08

D · Potential for more than minimal harm 2019-02-12

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2019-04-08

D · Potential for more than minimal harm 2019-02-12

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2019-04-08

D · Potential for more than minimal harm 2019-02-12

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2019-04-08

Penalties and ownership

What sits behind the stars

Ownership

Bayliss, Dawn

Corporate Officer · Individual

0% 1 facilities 2022-07-14

Kobis, David

Corporate Officer · Individual

0% 1 facilities 2022-05-31

Mayer, Cheryl

Contracted Managing Employee · Individual

0% 1 facilities 1985-09-18

Wright, Mark

Corporate Officer · Individual

0% 1 facilities 2022-06-06

Nearby options

Other facilities in reach

#1

East Side Nursing Home

Warsaw, NY

3-star overall rating with 4-star inspections with $8,990 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

Overall: 3 / 5
Health: 4 / 5
Staffing: 1 / 5
Fines: $8,990

#2