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)
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
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
Staffing
Hours and turnover
RN hours / resident day
0.43
Registered nurse staffing
LPN hours / resident day
1.29
Licensed practical nurse staffing
Aide hours / resident day
2.34
Nurse aide staffing
Weekend hours
3.38
Weekend nurse staffing
RN turnover
8%
Annual RN turnover
Total nurse turnover
28%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
Survey summary
Recent inspection cycles
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
Kobis, David
Corporate Officer · Individual
Mayer, Cheryl
Contracted Managing Employee · Individual
Wright, Mark
Corporate Officer · Individual
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
#2
Livingston County Center for Nursing and Rehabilit
Mount Morris, NY
2-star overall rating with 2-star inspections with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Leroy Village Green Residential Health C F, Inc
Leroy, NY
5-star overall rating with 5-star inspections with 1 recent health deficiencies
Jump out