Inspection Reports for
Waterville Residential Care Center
220 Tower Street, Waterville, NY, 13480
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
96% worse than New York average
New York average: 5.1 deficiencies/year
Deficiencies per year
32
24
16
8
0
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Aug 27, 2025
Visit Reason
The abbreviated survey was conducted to evaluate compliance with care standards following concerns about resident treatment and accident prevention.
Findings
The facility failed to provide appropriate treatment and care for Resident #1 during a change in condition that led to death during transport. Additionally, the facility did not ensure adequate supervision and implementation of fall prevention interventions for Residents #1 and #2, resulting in multiple falls and insufficient documentation or follow-up assessments.
Deficiencies (2)
F 0684: The facility did not ensure residents received treatment and care according to professional standards. Resident #1 exhibited a change in condition and expired during transport without documented assessment or consistent staff communication.
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision or implement fall prevention interventions for Residents #1 and #2, resulting in multiple falls and incomplete assessments.
Report Facts
Falls documented for Resident #1: 9
Falls documented for Resident #2: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #10 | Named in medication administration and resident assessment issues related to Resident #1 | |
| Licensed Practical Nurse Unit Manager #5 | Provided progress notes and statements regarding Resident #1's condition and fall incident reviews | |
| Certified Nurse Aid #6 | Reported concerns about Resident #1 and Resident #2 fall risks and interventions | |
| Director of Nursing | Interviewed regarding Resident #1's change of condition and fall incident review processes |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Aug 27, 2025
Visit Reason
Two Level 2 standard health citations related to accident hazards and quality of care, both isolated incidents with no severe systemic problems.
Findings
Two Level 2 standard health citations related to accident hazards and quality of care, both isolated incidents with no severe systemic problems.
Deficiencies (2)
Free of accident hazards/supervision/devices
Quality of care
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Oct 10, 2024
Visit Reason
The inspection was a recertification survey conducted from 10/7/2024 to 10/10/2024 to assess compliance with regulatory requirements for nursing home operations.
Findings
The facility was found deficient in multiple areas including maintaining a safe, clean, and homelike environment; providing appropriate activities for residents; pressure ulcer care; medication storage and labeling; food palatability and temperature; and food safety and sanitation in the kitchen and dining areas.
Deficiencies (6)
F 0584: The facility did not ensure a safe, clean, comfortable, and homelike environment. Issues included urine odors, dirty and sticky floors, unclean and damaged areas, and missing ceiling tiles with water leaks.
F 0679: The facility did not provide an ongoing program of activities meeting the interests and preferences of Resident #28, who was often left isolated and not engaged in activities.
F 0686: Resident #30 with a Stage 3 pressure ulcer was not consistently provided pressure relieving heel boots while in bed as ordered, risking skin breakdown.
F 0761: The facility did not ensure drugs and biologicals were properly labeled with expiration dates and stored securely. Medication and treatment carts were found unlocked and unattended with expired syringes and unlabeled insulin pens.
F 0804: Food served was not palatable or at safe temperatures. Test trays showed hot foods below recommended temperatures and residents reported food was cold, bland, and missing items.
F 0812: Food was not procured, stored, prepared, distributed, and served in accordance with professional standards. Observations included expired, moldy, undated, and dented food items, sanitizer issues, and a dish machine not properly heated.
Report Facts
Expired medication syringes: 3
Expired juice containers: 7
Dish machine rinse temperature: 150
Food temperature: 124
Food temperature: 120
Sanitizer test reading: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #7 | Certified Nurse Aide | Reported strong urine smell in resident room and lack of mattress cleaning guidance |
| Licensed Practical Nurse #8 | Licensed Practical Nurse | Noted urine smell and housekeeping issues with dining rooms |
| Licensed Practical Nurse Unit Manager #9 | Licensed Practical Nurse Unit Manager | Reported responsibility for dining room cleaning after dinner and urine odor observations |
| Housekeeper #10 | Housekeeper | Described housekeeping schedules and urine odor cleaning procedures |
| Housekeeping Supervisor #11 | Housekeeping Supervisor | Reported staffing shortages and cleaning expectations |
| Director of Maintenance #12 | Director of Maintenance | Acknowledged maintenance issues with plywood, tiles, and ceiling leaks |
| Activities Director #6 | Activities Director | Documented resident activity preferences and attendance; acknowledged failure to engage Resident #28 |
| Certified Nurse Aide #16 | Certified Nurse Aide | Cared for Resident #30 and noted pressure relieving heel boots were not consistently applied |
| Licensed Practical Nurse #17 | Licensed Practical Nurse | Discussed pressure ulcer care and documentation for Resident #30 |
| Certified Nurse Aide #15 | Certified Nurse Aide | Cared for Resident #30 and noted importance of heel boots |
| Licensed Practical Nurse Manager #13 | Licensed Practical Nurse Manager | Discussed pressure ulcer care and documentation compliance |
| Licensed Practical Nurse #18 | Licensed Practical Nurse | Explained medication labeling policies and concerns about expired insulin |
| Assistant Director of Nursing | Assistant Director of Nursing | Discussed medication and treatment cart security |
| Administrator | Administrator | Acknowledged expectations for treatment cart security and facility conditions |
| Food Service Director | Food Service Director | Reported on food temperatures, expired food items, kitchen sanitation, and refrigerator maintenance |
| Certified Nurse Aide #26 | Certified Nurse Aide | Reported resident complaints about food quality |
| Licensed Practical Nurse #14 | Licensed Practical Nurse | Reported resident complaints about food quality |
| Dietary Aide #27 | Dietary Aide | Described food temperature standards and resident complaints |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 20
Date: Oct 10, 2024
Visit Reason
Multiple Level 2 standard health and life safety code citations including activities, food sanitation, drug labeling, nutritive value, environment, pressure ulcer treatment, and various life safety code issues. Most deficiencies corrected by late November 2024.
Findings
Multiple Level 2 standard health and life safety code citations including activities, food sanitation, drug labeling, nutritive value, environment, pressure ulcer treatment, and various life safety code issues. Most deficiencies corrected by late November 2024.
Deficiencies (20)
Activities meet interest/needs each resident
Food procurement,store/prepare/serve-sanitary
Label/store drugs and biologicals
Nutritive value/appear, palatable/prefer temp
Safe/clean/comfortable/homelike environment
Treatment/svcs to prevent/heal pressure ulcer
Cooking facilities
Corridor - doors
Egress doors
Electrical equipment - testing and maintenanc
Electrical systems - essential electric syste
Elevators
Fire alarm system - testing and maintenance
Hazardous areas - enclosure
Interior nonbearing wall construction
Means of egress - general
Portable fire extinguishers
Sprinkler system - installation
Sprinkler system - maintenance and testing
Subdivision of building spaces - smoke barrie
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 15, 2024
Visit Reason
One Level 2 standard health citation for reporting to national health safety network, widespread scope, no severe systemic problems.
Findings
One Level 2 standard health citation for reporting to national health safety network, widespread scope, no severe systemic problems.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 8, 2024
Visit Reason
One Level 2 standard health citation for reporting to national health safety network, widespread scope, no severe systemic problems.
Findings
One Level 2 standard health citation for reporting to national health safety network, widespread scope, no severe systemic problems.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Mar 11, 2024
Visit Reason
One Level 2 standard health citation for reporting to national health safety network, widespread scope, no severe systemic problems.
Findings
One Level 2 standard health citation for reporting to national health safety network, widespread scope, no severe systemic problems.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Nov 20, 2023
Visit Reason
One Level 2 standard health citation for reporting to national health safety network, widespread scope, no severe systemic problems.
Findings
One Level 2 standard health citation for reporting to national health safety network, widespread scope, no severe systemic problems.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jun 12, 2023
Visit Reason
One Level 2 standard health citation for reporting to national health safety network, widespread scope, no severe systemic problems.
Findings
One Level 2 standard health citation for reporting to national health safety network, widespread scope, no severe systemic problems.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Renewal
Deficiencies: 1
Date: Mar 7, 2023
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with food storage, preparation, and sanitation standards in the facility's kitchen and food service areas.
Findings
The facility failed to ensure food was stored, prepared, and served in accordance with professional food safety standards. Issues included improper storage of raw meat above ready-to-eat foods, unclean floors and equipment, inadequate dishwasher rinse temperatures, and improper garbage disposal.
Deficiencies (1)
F 0812: Food storage was improper with shelving units and kitchen equipment stored under a sewage drain line and raw hamburger patties stored above ice cream cups. Floors and equipment including the #10 can opener were soiled with food debris. The commercial dishwasher did not achieve required rinse temperatures of 180°F, operating at 160°F instead. Garbage was improperly stored in the kitchen air handler closet.
Report Facts
Dishwasher temperature: 160
Dishwasher temperature: 150
Dishwasher temperature: 180
Dishwasher temperature: 150
Raw hamburger patties weight: 10
Sewage drain line length: 12
Sewage drain line diameter: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Interviewed regarding food storage, dishwasher temperatures, and garbage disposal issues | |
| Dietary staff #11 | Interviewed about dishwasher temperature logging | |
| Dietary staff #12 | Interviewed about dishwasher temperature logging | |
| Dietary staff #13 | Interviewed about dishwasher temperature logging |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 7
Date: Mar 7, 2023
Visit Reason
Level 2 standard health citation for food procurement sanitation and multiple Level 2 life safety code citations including electrical equipment, hazardous areas, illumination, and means of egress. Most deficiencies corrected by late March and April 2023.
Findings
Level 2 standard health citation for food procurement sanitation and multiple Level 2 life safety code citations including electrical equipment, hazardous areas, illumination, and means of egress. Most deficiencies corrected by late March and April 2023.
Deficiencies (7)
Food procurement,store/prepare/serve-sanitary
Electrical equipment - power cords and extens
Electrical equipment - testing and maintenanc
Electrical systems - essential electric syste
Hazardous areas - enclosure
Illumination of means of egress
Means of egress - general
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Mar 6, 2023
Visit Reason
One Level 2 standard health citation for reporting to national health safety network, widespread scope, no severe systemic problems.
Findings
One Level 2 standard health citation for reporting to national health safety network, widespread scope, no severe systemic problems.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Dec 27, 2022
Visit Reason
One Level 2 standard health citation for reporting to national health safety network, widespread scope, no severe systemic problems.
Findings
One Level 2 standard health citation for reporting to national health safety network, widespread scope, no severe systemic problems.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Dec 20, 2022
Visit Reason
Two Level 2 standard health citations for notification of changes and quality of care, isolated scope, corrected by January 2023.
Findings
Two Level 2 standard health citations for notification of changes and quality of care, isolated scope, corrected by January 2023.
Deficiencies (2)
Notify of changes (injury/decline/room, etc. )
Quality of care
Inspection Report
Capacity: 60
Deficiencies: 1
Date: May 9, 2022
Visit Reason
One Level 2 standard health citation for reporting to national health safety network, widespread scope, no severe systemic problems.
Findings
One Level 2 standard health citation for reporting to national health safety network, widespread scope, no severe systemic problems.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Dec 1, 2021
Visit Reason
One Level 2 standard health citation for accident hazards, isolated scope, corrected by December 2021.
Findings
One Level 2 standard health citation for accident hazards, isolated scope, corrected by December 2021.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Nov 22, 2021
Visit Reason
One Level 2 standard health citation for reporting to national health safety network, widespread scope, no severe systemic problems.
Findings
One Level 2 standard health citation for reporting to national health safety network, widespread scope, no severe systemic problems.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Sep 11, 2020
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, developing and implementing comprehensive care plans, ensuring appropriate use of contracture devices, proper labeling and storage of medications, serving food at safe and palatable temperatures, and maintaining proper food storage temperatures.
Deficiencies (10)
F 0584: The facility did not ensure a safe, clean, and homelike environment on one unit, with multiple resident areas in disrepair including a rusty ice machine grate, damaged countertops, loose toilet paper holders, missing base molding, and damaged walls and toilet seats.
F 0584: The Plant Operations Director was unaware of the maintenance issues and could not find work orders for the identified deficiencies.
F 0656: The facility failed to develop and implement a complete care plan for Resident #48, who did not have skin breakdown prevention boots in place as planned, increasing risk of pressure ulcers.
F 0656: Staff were unable to locate the resident's pressure relieving boots, and communication between nursing and therapy regarding the boots was inadequate.
F 0688: Residents #31 and #48 with limited range of motion did not have hand contracture devices in place as care planned, risking further decline in mobility.
F 0688: Therapy was responsible for issuing hand orthotics but failed to provide replacements timely, and nursing staff were unaware of changes to care plans.
F 0761: Multiple expired medications and undated opened multi-dose vials were found in two medication rooms and two medication carts, violating medication storage and labeling standards.
F 0804: Food and drinks were not served at safe and palatable temperatures for three meals reviewed, including lukewarm chipped beef, cold ham and cheese sandwiches, and lukewarm pancakes and milk.
F 0804: Food temperature logs were incomplete, and staff failed to record temperatures of food on steam tables prior to serving dinner on 9/9/20.
F 0812: The three-door nourishment cooler was not maintained at 41 degrees Fahrenheit or less, with air temperatures measured at 50 degrees and milk temperatures up to 56 degrees Fahrenheit.
Report Facts
Expired medication expiration date: 4
Food temperature: 118
Food temperature: 51
Food temperature: 81
Food temperature: 78
Food temperature: 95
Food temperature: 61
Cooler air temperature: 50
Milk temperature: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Plant Operations Director | Named in relation to unawareness of maintenance issues and missing work orders. | |
| CNA #6 | Certified Nurse Aide | Interviewed regarding resident care and use of pressure boots and hand orthotics. |
| LPN Unit Manager #5 | Licensed Practical Nurse Unit Manager | Interviewed regarding care plan implementation and communication with therapy. |
| Physical Therapy Assistant (PTA) #7 | Physical Therapy Assistant | Interviewed regarding supply and use of pressure relieving boots and hand orthotics. |
| CNA #3 | Certified Nurse Aide | Interviewed regarding use of hand contracture devices for Resident #31. |
| Occupational Therapist #4 | Occupational Therapist | Interviewed regarding contracture care and responsibility for care plan updates. |
| LPN #12 | Licensed Practical Nurse | Observed expired medications and discussed medication disposal. |
| Temporary Co-Food Service Supervisor #9 | Temporary Co-Food Service Supervisor | Interviewed regarding food temperature monitoring and nourishment cooler temperatures. |
| Food Service Worker #10 | Interviewed regarding failure to record food temperatures on steam tables. | |
| Temporary Co-Food Service Supervisor #11 | Temporary Co-Food Service Supervisor | Interviewed regarding items stored in nourishment cooler. |
| Administrator | Administrator | Interviewed regarding food handling and nourishment cooler practices. |
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