The resident at Waterville Residential Care Center had been identified as a fall risk due to confusion, gait problems, and a history of falls before admission. Their care plan required hourly safety checks, non-slip socks, and keeping the call bell within reach.
None of that happened consistently.
On June 13 at 8:00 PM, staff found the resident lying on the floor beside their roommate's bed. The person couldn't say if they were hurt or had hit their head. Staff helped them back to bed and added a new intervention: attach the bed remote to the headboard.
The next night brought two more falls. At 11:45 PM on June 14, the resident was found sitting upright on the floor, taking off their clothes. They winced when staff touched their right shoulder, but no registered nurse assessed them. Less than two hours later at 1:45 AM, staff discovered the person lying half out of bed with their upper body on the floor. The inspection report noted "scattered bruising from previous falls."
Two days later on June 16, staff found the resident scooting down the hallway on the floor, away from their abandoned wheelchair. They lifted the person back into the chair. Despite four falls in three days, there was no documentation that anyone reviewed or revised the care plan.
When inspectors arrived in August, they found the resident lying sideways across their bed with both feet hanging off the edge and their head at the foot of the bed. The call bell lay on the floor under the headboard. The bed controls were under the middle of the bed. The non-slip socks were also under the middle of the bed.
The resident was wearing regular socks.
The next day, inspectors returned. The call bell, bed remote, and non-slip socks remained under the bed.
Licensed Practical Nurse Unit Manager #5 told inspectors the resident was "a high fall risk" who would get up and start walking, often forgetting their walker or wheelchair. The person had previously been independent but now required supervision for transfers.
Licensed Practical Nurse #10 said the resident's fall interventions included a low bed, safety checks, and therapy referrals. After falls, the team tried to figure out why they happened through medical workups, lab tests, and medication reviews.
But Certified Nurses Aid #6 didn't know why the call bell was on the floor or why the resident wasn't wearing non-slip socks. The aide said the resident "liked to stand up and walk on their own" and had a low bed and floor mats.
The Director of Nursing explained that after any fall, staff should notify a supervisor or registered nurse before moving the resident. A registered nurse didn't always assess residents before they were moved, "but staff should not move residents until a direction from a registered nurse or provider was given."
Fall incident reports were reviewed every morning with the interdisciplinary team, who looked at root causes and interventions. If an intervention wasn't followed but wasn't the root cause of the fall, "they did not focus on that."
The nursing director acknowledged problems with documentation. Staff statements should be taken at the time of incidents, "but this had not happened every time and they were concerned with the lack of documentation."
During one inspection observation, another resident was spotted in the hallway wearing "regular fuzzy socks" instead of the required non-slip footwear.
The facility's comprehensive care plan, revised in July, had documented that the frequently-falling resident needed interventions including hourly safety checks, non-slip socks on their feet, bed controls attached to the headboard, and the call light within reach. But when inspectors made unannounced visits, basic safety equipment lay scattered under the bed while the confused resident lay in a position that could easily lead to another fall.
The inspection found the facility failed to ensure residents received proper treatment and care to prevent accidents and maintain the highest level of physical well-being. The violation affected few residents but created minimal harm or potential for actual harm.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Waterville Residential Care Center from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Waterville Residential Care Center
- Browse all NY nursing home inspections