WYOMING COUNTY COMMUNITY HOSPITAL S N F

Nursing Home Inspector

400 NORTH MAIN STREET
WARSAW, NY 14569
Wyoming County
Phone: 585-786-2233
Provider Number: 335034
Last Inspection: 09/29/2017

About the Nursing Home

Number of Beds: 138
Number of Residents: 132
Beds Available: 6
Percent Occupancy: 96%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Both
Ownership: Government - County
Within Hospital?: YES

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

21

Facility 		18

County 		14

NY 		20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 
21

2017		 43

2016		 33

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

9/29/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 11/29/2017
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 11/29/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 11/29/2017
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 11/29/2017
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 11/29/2017
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 11/29/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 11/29/2017
 

7/12/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 9/9/2016
 
Failed To: Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. Pattern : Potential 3 9/9/2016
 
Failed To: Provide medically-related social services to help each resident achieve the highest possible quality of life. Pattern : Minimal 4 9/9/2016
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Pattern : Potential 3 9/9/2016
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 9/9/2016
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 9/9/2016
 
Failed To: Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. Isolated : Minimal 3 9/9/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 9/9/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Immediate 6 9/9/2016
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 9/9/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 9/9/2016
 
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Pattern : Immediate 6 9/9/2016
 

5/14/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep each resident free from physical restraints, unless needed for medical treatment. Isolated : Minimal 3 7/15/2015
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 7/15/2015
 
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Isolated : Minimal 3 7/15/2015
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 7/15/2015
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Pattern : Minimal 4 7/15/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 7/15/2015
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 7/15/2015
 
Failed To: Keep all essential equipment working safely. Isolated : Minimal 3 7/22/2015
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Pattern : Minimal 4 7/15/2015
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Pattern : Minimal 4 7/15/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

1/22/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 3/11/2016
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg NY State Avg
Number of Residents 132 101.50 167.28
Registered Nurses 0.72 0.66 0.74
Licensed Practical / Vocational Nurses 1.27 1.14 0.84
Certified Nursing Assistants 2.55 2.22 2.30
Total Staff Hours 4.53 4.02 3.88

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% NY State Avg%
of high risk long-stay residents with pressure ulcers 6 3 6
of long-stay residents assessed and appropriately given the pneumococcal vaccine 97 97 95
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 99 99 96
of long-stay residents experiencing one or more falls with major injury 4 3 2
of long-stay residents who have depressive symptoms 6 5 8
of long-stay residents who lose too much weight 10 9 6
of long-stay residents who received an antianxiety or hypnotic medication 23 21 15
of long-stay residents who received an antipsychotic medication 8 12 13
of long-stay residents who self-report moderate to severe pain 4 3 3
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 15 19 16
of long-stay residents whose need for help with daily activities has increased 10 16 13
of long-stay residents with a catheter inserted and left in their bladder 1 3 1
of long-stay residents with a urinary tract infection 3 2 3
of low risk long-stay residents who lose control of their bowels or bladder 59 61 50
of short-stay residents assessed and appropriately given the pneumococcal vaccine 79 87 81
of short-stay residents who had an outpatient emergency department visit 12 13 9
of short-stay residents who made improvements in function 66 73 68
of short-stay residents who newly received an antipsychotic medication 1 2 1
of short-stay residents who self-report moderate to severe pain 14 11 9
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 85 92 82
of short-stay residents who were rehospitalized after a nursing home admission 28 29 21
of short-stay residents who were successfully discharged to the community 51 45 48
of short-stay residents with pressure ulcers that are new or worsened 0 0 0