Waterville Residential Care Center

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

wake up at all when they were put in the wheelchair. Before they left the room, the resident did not look good, and their hand was cold and yellow.During an interview on [DATE REDACTED] at 12:30 PM, the Director of Nursing stated they were not made aware Resident #1 had a change of condition on [DATE REDACTED]. They received

a phone call on [DATE REDACTED] asking about Resident #1's code status, as they were in the process of giving the resident cardiopulmonary resuscitation. They informed them resident was a full code and wanted everything done. They heard someone on the other side of the phone pronounce the resident's death. During an

interview on [DATE REDACTED] at 1:05 PM, Occupational Therapist #7 stated the resident was on their list to provide therapy to on [DATE REDACTED]. When they visited the resident's room, the resident did not look medically stable, and

they decided not to treat them. The resident looked exhausted or was in a medical event. Later that morning, nursing requested help getting Resident #1 out of bed to the wheelchair. The transfer did not go well. They attempted to wake the resident, but they continued to not be alert. They asked if someone should perform a sternal rub and was told by Licensed Practical Nurse #10, they already had multiple times. The resident was in an upright slumped position with their head against the wall and their feet on the floor. They told staff multiple times the resident did not look very good but was told they had to go for their appointment. They reported the situation to their supervisor after the incident. They stated to nursing the resident should not go to the appointment. They saw the resident raise their hand to their head but noted it as a non-purposeful movement.10 NYCRR 415.12

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Waterville Residential Care Center

220 Tower Street Waterville, NY 13480

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

or more falls with injury since the last assessment. The Comprehensive Care Plan, revised on 07/03/2025, documented the resident was at risk for falls related to confusion, gait/balance problems, and had a history of falls prior to admission. Interventions included to meet their needs, ensure call light was within reach, slipper socks on feet, Velcro bed control to head of bed, and safety checks every hour.Resident #2 Fall Incident Reports documented:-on 6/13/2025 at 8:00 PM: resident was lying on the floor on right side at the foot of their roommate's bed. Vitals signs were taken, and the resident was assessed by a registered nurse.

The resident was unable to state if they were in pain or if they hit their head. The resident was assisted back to bed. Interventions added to the care plan included to attach remote to the head of the bed.-on 6/14/2025 at 11:45 PM: resident found sitting upright on the floor to the right of their bed, disrobing. They were unable to state what happened and appeared to wince when their right shoulder was palpated. There was no documented assessment by a registered nurse.-on 6/14/2025 at 1:45 AM: resident found lying half out of bed with upper part of body on the floor to the left of their bed. Scattered bruising from previous falls were noted. The resident was unable to state what happened and was put back into bed.-on 6/16/2025 at 9:55 PM: resident was found scooting on the floor down the hallway away from their wheelchair. The resident was lifted from the floor and put back in their wheelchair. There was no documentation of care plan

review or revision.The following observations of Resident #2 were made:-on 8/5/2025 at 11:21 AM: Resident #2 was lying on their left side with both feet hanging off the bed, with their head at the foot of the bed. The call bell was on the floor under the head of the bed, the bed controls were under the middle of the bed, and non-skid socks were under the middle of the bed. The resident was wearing regular socks.-on 8/6/2025 at 12:11 PM: the resident's call bell, bed remote and slipper socks remained under the bed. -on 8/6/2025 at 4:00 PM: Resident #1 was in the hallway in their wheelchair. The resident was not wearing non-skid socks and was wearing regular fuzzy socks.During an interview on 8/6/2025 at 10:20 AM, Licensed Practical Nurse Unit Manager #5 stated Resident #2 was a high fall risk. They would get up and start walking and often would forget their walker or wheelchair. They previously ambulated independently and did transfer out of bed but now they required supervision/touch assistance.During an interview on 8/6/2025 at 11:00 AM, Licensed Practical Nurse #10 stated Resident #2's fall interventions included low bed, safety checks, and physical therapy/occupational therapy referrals. After their falls, the team tried to figure out why they fell, included medical work ups, labs, any medication changes, and included any needed interventions.During an interview on 8/6/2025 at 11:53 AM, Certified Nurses Aid #6 stated Resident #2 liked to stand up and walk on their own. They had a low bed and floor mats. They did not know why their call bell was on the floor or why non-skid socks were not on.During an interview on 8/6/25 at 12:30 PM, the Director of Nursing stated anytime a resident fell, staff should notify a supervisor or a registered nurse in

the building, themselves, and the provider. The nurses moved the resident. A registered nurse did not always assess the resident prior to being moved but staff should not move residents until a direction from a registered nurse or provider was given. Nurses filled out the incident report. Reports were reviewed every morning with the interdisciplinary team. The root cause and interventions were reviewed. If an intervention was not followed, and was not the root cause, they did not focus on that. The team updated the care plan and care card at the time of the meeting. Nurse Managers updated the care plans. It was a work in progress to determine the cause of calls. Staff statements needed to be taken at the time of the incident, but this had not happened every time and they were concerned with the lack of documentation.10NYCRR 415.12 (h)(1)

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