Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at East Side Nursing Home during CMS and state inspections, most recent first.
A resident with post-hip fracture aftercare, CHF, and COPD, who was dependent on staff for wheelchair mobility off the unit, was transported to and from an outside appointment in the facility’s van. Although the wheelchair was anchored to the van floor, the driver and transport aide did not apply the required shoulder and lap belts before driving. During the return trip, the driver braked abruptly to avoid traffic, and the unrestrained resident was thrown from the wheelchair onto the van floor, sustaining a nasal fracture, abrasions, and pain. The driver later admitted forgetting to secure the seat belt, while the aide reported believing a claimed refusal could be honored and proceeded without notifying a supervisor. The facility’s transport policy at the time lacked a verification check system to ensure residents were properly secured and did not direct staff on how to respond if a resident refused safety restraints, contributing to the failure to provide adequate supervision and assistance devices to prevent this accident.
A resident reported ceiling and window leaks, with rags and towels on the windowsill holding rusty, moldy water and staff aware of the issue. Surveyors observed wet and stained ceiling tiles, rust-colored water stains in hallways and resident rooms, and a chipped, rust-colored dining room windowsill attributed by the RM Supervisor to roof leaks. Residents stated the leaks had been present for a long time and the stained areas were not homelike.
A resident with an arterial ulcer, dementia, and a history of osteomyelitis did not receive ordered wound care consistently, with multiple missed dressing changes and refusals documented on the TAR. The wound on the left ankle was observed with drainage strikethrough, and the chart did not show provider notification when treatments were refused or not completed. Staff confirmed that blanks on the TAR meant care was not done and that the provider should have been informed.
A resident with Parkinson’s disease and an order for a regular diet with ground meats was served a full chicken breast instead of the required ground texture during a meal pass. Staff placed the wrong plate in front of the resident, another resident noticed the mix-up, and the RN later exchanged the plates. Interviews confirmed the resident should have received ground chicken based on the diet order, care plan, and SLP recommendations.
The facility did not ensure that newly admitted residents and/or their representatives received a written summary of the baseline care plan within 48 hours of admission, as required by facility policy. For multiple residents with conditions such as dementia, CHF, COPD, atrial fibrillation, schizoaffective disorder, and dysphagia, records showed that baseline care plans were completed and verbally reviewed by a social worker with the resident and/or family, but there was no documentation that a written summary including admission orders, dietary instructions, therapy, and social services was provided or that a paper copy was declined. The DON reported that the social worker was responsible for providing these copies and was not aware that written summaries were not being consistently given.
Failure to Secure Wheelchair-Bound Resident With Seat Belts During Van Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident was safely secured in the facility’s wheelchair transport van, resulting in the resident being thrown from the wheelchair during an abrupt stop and sustaining injuries. The resident had diagnoses including post-orthopedic aftercare following a hip fracture repair, congestive heart failure, and COPD, and was assessed as cognitively intact, able to understand and be understood by others. The resident’s care plan and Kardex documented that the resident was dependent on staff for wheelchair mobility off the unit and required extensive assistance of one staff member with a rolling walker and gait belt for transfers. On the day of the incident, the resident was being transported back from an outside medical appointment in the facility’s van by a driver and a transport aide. The wheelchair was anchored to the van floor with four anchor points, but the shoulder and lap belts were not applied. The facility’s accident and incident report documented that the van was traveling at approximately 45 miles per hour when traffic in front stopped abruptly, causing the driver to brake suddenly. As a result, the resident, who was sitting upright in the wheelchair, fell forward out of the wheelchair onto the van floor and reported pain to the nose and knees. Emergency Medical Services were called, and the resident was transported to the emergency room, where they were diagnosed with a nasal fracture and abrasions, and reported associated pain. Interviews and documentation revealed conflicting accounts regarding whether the resident refused the seat belt, but confirmed that the required shoulder and lap belts were not in use at the time of transport. The facility’s five-day investigation documented that the driver admitted to not securing the resident with the seat belts, stating, "No, I forgot to put it on." The transport aide stated that this was their first day working independently, that the resident had refused the seat belt, and that the driver said it was acceptable to proceed. The accident and incident report did not document any refusal by the resident to wear the belts, and in a later interview the resident stated they did not refuse to fasten the seat belt and did not know why staff had not fastened it. The Medical Director stated that if the resident had been properly restrained according to Department of Transportation guidelines and facility policy, the fall from the wheelchair and resulting harm would not have occurred. Facility leadership, including the Assistant Administrator, Director of Maintenance, and DON, stated that drivers were trained not to move the van until all passengers were strapped in and that staff should have contacted a supervisor and refused to transport if a resident did not have safety restraints applied. The facility’s written policy for operation of the transport van at the time of the incident included training on the wheelchair lift and restraint system but did not include a verification check system to ensure residents were appropriately secured prior to transport or instructions on what to do if a resident refused safety requirements. The Director of Maintenance confirmed that, at the time of the accident, the wheelchair was secured to the floor but the shoulder and lap belts were not applied, which allowed the resident to be thrown from the wheelchair during the abrupt stop. The surveyors determined that this failure to provide adequate supervision and assistance devices to prevent accidents resulted in actual harm to the resident and constituted Immediate Jeopardy and Substandard Quality of Care, with the likelihood of serious harm, serious impairment, serious injury, or death to residents’ health and safety.
Removal Plan
- Driver #1 was terminated.
- Transport Aide #1 was re-educated.
- The policy titled "Operation of the 2011 Ford Passenger Van" was revised to include a three-level safety verification process for every resident transported.
- Transportation verification logs were created for each trip to document each verification step and signature of completion.
- Safety signage inside the transport van was enlarged and relocated.
- 100% of transportation staff were educated.
- Nursing, recreational, therapy, and social work staff were educated regarding the verification system, transport policy, and resident safety.
- Training was continued and expanded to include nutritional and housekeeping services staff.
- Transportation audits were conducted to monitor corrective actions and ensure implementation of facility protocols for resident safety during transportation.
- Audit results were reviewed weekly by Administration and reported during monthly QAPI meetings.
Stained Ceilings and Ongoing Roof Leaks on Third Floor
Penalty
Summary
The facility did not ensure housekeeping and maintenance services were provided to maintain a sanitary, orderly, and comfortable interior on the third floor. During observation and interview, Resident #84 stated their ceiling and window leaked, that rags on the windowsill were filled with rusty moldy water, and that towels had been left there since spring. The resident also stated tape had been placed on the wall where the leak was coming through and that staff knew about it but had not done anything about it. Surveyors observed multiple signs of water intrusion and damage throughout the third floor. A discolored gray ceiling tile appeared wet from an active leak outside the shower room, and there were rust-colored and gray water stains in hallway ceiling tiles between resident rooms, near the nursing station and elevator, and in the stairwell area. In the third-floor dining room, a long section of the windowsill was chipped and rust-colored, and the Regional Maintenance Supervisor stated it was from roof leaks when it rained. In a resident room, brown stained ceiling tiles were observed near the window, and the resident stated the ceiling had leaked for more than a year and water came down the window. Additional stained ceiling tiles and discolored towels were observed in another resident room, and residents stated the stains bothered them and were not homelike.
Missed Wound Care and Lack of Provider Notification
Penalty
Summary
Resident #80’s arterial ulcer to the left medial malleolus was not treated in accordance with physician orders and the facility’s wound care policy. The resident had diagnoses including a history of osteomyelitis, arterial ulcers, and dementia, and the care plan directed staff to monitor and document skin changes, follow the facility skin breakdown policy, and reapproach or have another staff member attempt care if the resident refused. The physician ordered wound care on 12/18/2025, then revised orders on 01/02/2026 and 01/16/2026 continued to require cleansing the wound, applying prescribed topical treatments, securing with bordered gauze, and changing the dressing twice daily. Treatment Administration Records showed multiple missed wound care treatments over several periods. There was no documented evidence that the dressing was changed for nine shifts between 12/19/2025 and 12/29/2025, and no documented evidence of dressing changes for seven shifts between 01/03/2026 and 01/16/2026. From 01/23/2026 through 01/27/2026, the record again showed missed treatments, including no documentation for the day shift on 01/24/2026 and the day and evening shifts on 01/25/2026. Several evening shifts were documented as refused by the resident, and one day shift was signed off by the DON. During observation on 01/27/2026, the resident had a gauze dressing on the left inner ankle dated 01/23 with visible dark red strikethrough. The interdisciplinary progress notes did not document that the provider was notified of refusals or missed treatments. Staff interviews confirmed that blanks on the TAR meant treatments were not completed and that providers should be notified when treatments are not completed or when there are repeated refusals. The wound assessment on 01/28/2026 described thick seropurulent exudate and stalled healing, and the NP noted the wound could turn into osteomyelitis quickly. The NP also stated the resident had a history of refusing care and was on comfort care.
Wrong Texture Meal Served to Resident with Ground Meat Order
Penalty
Summary
The facility did not ensure that a resident received food prepared in the ordered form designed to meet individual needs. Resident #43 had diagnoses including Parkinson’s disease, hypertension, and anorexia, was cognitively intact, and was ordered a regular diet with ground meat texture. The resident’s care plan, Kardex, physician order, and speech therapy discharge summary all reflected the need for ground or mechanically altered meats because the resident had difficulty efficiently chewing regular meat and tolerated ground textures better. During a lunch meal observation, Activity Aide #1 placed a full, unground chicken breast in front of Resident #43 and placed the ground chicken plate off to the side. Another resident questioned whether the meals had been mixed up, and the ground chicken plate was moved to the wrong resident before the surveyor alerted the RN Educator/Infection Preventionist. The RN Educator/Infection Preventionist then exchanged the plates, stating it was acceptable because no one had touched them. The meal ticket for Resident #43 showed the resident should have received ground grilled chicken breast. Interviews confirmed that the resident should have been served ground meat due to the ordered diet and Parkinson’s disease. The RN Educator/Infection Preventionist stated the activity aide was new and was only supposed to be observing, while the Director of Activities stated activity staff normally assist with tray passing in the dining room and that the aide had been instructed to observe. The Regional Food Service Director stated the tray delivery process involved placing two meals on one tray with corresponding meal tickets and handing the tray to nursing/activity staff at the kitchen doorway, and acknowledged the wrong texture meal should not have been served. The DON stated the resident was ordered a regular diet with ground meat and expected the chicken to be ground.
Failure to Provide Written Baseline Care Plan Summaries to Newly Admitted Residents
Penalty
Summary
The facility failed to provide newly admitted residents or their representatives with a written summary of the Baseline Care Plan within 48 hours of admission, as required by facility policy and 10 NYCRR 415.11. For eight of ten sampled residents, there was no documented evidence that a written summary of their initial care needs, including admission orders, dietary instructions, therapy, and social services, was given to them or their representatives. The facility’s policy dated 12/19/2022 required that a baseline care plan be developed within 48 hours of admission and that a paper copy summary be provided, or that a refusal of the copy be documented. However, records for multiple residents showed completed baseline care plans without any documentation that a written summary was provided or that it was declined. One resident with severe cognitive impairment and diagnoses including femur fracture, dementia, and anxiety had a baseline care plan dated shortly after admission, but there was no documentation that a written summary was provided to the resident’s representative, despite a social worker note indicating a meeting to review the plan of care. Another resident with severe cognitive impairment and diagnoses including dementia, CHF, and COPD had a baseline care plan and a documented meeting with the social worker and family to discuss the plan of care, but again no documentation that a written summary was provided. A third resident with moderately impaired cognition and diagnoses including atrial fibrillation, schizoaffective disorder, and dysphagia similarly had no documentation that a written summary of the baseline care plan was provided, despite a documented meeting with the resident and family. In an interview, the social worker stated that they verbally reviewed the baseline care plan and offered a copy, but did not document when a copy was offered or declined, and the DON stated they were not aware that copies were not being provided as required.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Warsaw
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wyoming County Community Hospitals Snf | 1 mi | ★★★★★ | 7 | 0 |
| Livingston County Center For Nursing And Rehabilit | 12.6 mi | ★★★★★ | 2 | 0 |
| Leroy Village Green Residential Health C F, Inc | 17.4 mi | ★★★★★ | 1 | 0 |
| Premier Genesee Center For Nrsg And Rehabilitation | 18.8 mi | ★★★★★ | 1 | 1 |
| The Grand Rehabilitation And Nursing At Batavia | 18.9 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.