ROCHESTER, NY - State health inspectors documented multiple serious care failures at Waterview Heights Rehabilitation and Nursing Center during a comprehensive survey conducted from March through May 2025, including inadequate wound care that led to pressure ulcer development, dangerous lapses in supervising residents at risk for choking, and systemic staffing shortages that left vulnerable residents without basic hygiene care for weeks.
Delayed Treatment Results in Pressure Ulcer Development
The facility's most concerning violation involved a resident who developed two stage 2 pressure ulcers after staff failed to promptly report and treat identified skin breakdown. According to the inspection report, staff members discovered skin breakdown on a resident's buttocks on March 14, 2025, but no medical provider was notified and no treatments were initiated for three days.
When nursing staff initially observed the skin breakdown on March 14, multiple certified nursing assistants reported seeing the affected area. One staff member stated they "noticed a reddened area to the resident's buttock" and informed a nurse, while another aide reported observing "several open areas on their buttocks that were red and bleeding." Despite these observations, no documentation appeared in the resident's medical record, no treatments were ordered, and no physician was notified of the condition.
By March 17, when a nurse practitioner finally examined the resident, the untreated skin breakdown had progressed to two distinct stage 2 pressure ulcers - one at the coccyx and another at the ischium. Stage 2 pressure ulcers involve partial thickness skin loss and represent a significant progression from initial skin breakdown.
The three-day delay in treatment violated fundamental wound care protocols. Pressure ulcers can develop rapidly when skin breakdown goes untreated, particularly in residents with diabetes and cognitive impairment who cannot reposition themselves or communicate discomfort effectively. Early intervention with barrier creams, repositioning schedules, and pressure-relieving surfaces can prevent progression to more serious wounds. The facility's own policy required staff to "evaluate, report and document potential changes in the skin" and ensure residents at risk received "prompt removal of wet/damp clothing or sheets."
Residents on Aspiration Precautions Left Unsupervised During Meals
Inspectors identified a pattern of residents with swallowing difficulties being left alone while eating, creating immediate choking and aspiration risks. The facility had 33 residents requiring aspiration precautions, yet observations revealed multiple instances where these vulnerable individuals ate meals without any staff supervision.
In one documented case, a resident requiring honey-thickened liquids for safe swallowing was observed drinking regular, unthinned coffee and hot water while coughing repeatedly. The resident was slouched in bed at a 45-degree angle rather than the required upright position, with no staff present. When asked, the resident stated, "damn, I keep coughing."
Another resident with documented aspiration pneumonia history was observed eating alone in bed, positioned at only 45 degrees rather than the required 90-degree upright position. Staff members acknowledged the resident "should have a staff member present in their room for meals, but they did not always have enough staff."
Aspiration occurs when food or liquids enter the lungs instead of the stomach, potentially causing pneumonia, respiratory distress, or death. Residents with dysphagia require specific positioning - typically sitting upright at 90 degrees - and close supervision to ensure they take small bites, pace their eating appropriately, and remain upright for 30-60 minutes after meals. Thickened liquids move more slowly, reducing the risk of liquids entering the airway before the swallow reflex engages.
The inspection revealed the facility's kitchen was sending regular coffee with thickener packets for nursing staff to mix, rather than pre-thickening liquids as required. This practice led to residents receiving incorrect liquid consistencies when staff failed to add the thickener or were unaware of the requirement.
Weeks Without Basic Hygiene Care
Four residents experienced extended periods without showers, nail care, or proper incontinence management due to inadequate staffing levels. Inspectors documented residents going up to 30 days without documented showers, despite facility policies requiring weekly bathing.
One resident with severe cognitive impairment was observed with "unwashed, stringy hair" and reported not having a shower for three weeks. The resident's care plan indicated they required supervision for bathing, but staff admitted the resident "did not receive a shower on their shower day because there was not enough staff."
Another resident was discovered by their visitor "soaked with urine" and wearing week-old socks. The visitor reported the resident had not received a shower "for at least three to four weeks." When questioned, nursing staff could not recall when the resident last received hygiene care.
A particularly troubling case involved a resident with contracted hands whose fingernails had grown so long they were "cutting into the skin." The resident also had a full beard they wanted shaved and complained of an itchy scalp, stating they "had not been shaved or had a shower in a long time." Long, untrimmed nails in contracted hands can cause skin breakdown, infection, and significant pain as the nails press into the palm when muscles tighten.
Most disturbingly, one resident was observed remaining in urine-soaked clothing from 12:52 PM until after 4:20 PM, with pants "wet throughout the groin area almost down to the knees with a foul odor of urine." Extended exposure to urine and feces breaks down skin integrity, creating conditions for pressure ulcer development, urinary tract infections, and painful skin irritation.
Additional Issues Identified
Beyond these major violations, inspectors documented numerous other care failures throughout the facility. A resident's custom hand splints, designed to prevent contractures and maintain range of motion, were not being applied despite occupational therapy recommendations. After months without the prescribed splints, the resident experienced complete loss of range of motion in their hands, reversing all rehabilitation progress.
The facility also failed to properly manage specialized medical equipment. A resident with a nephrostomy tube - a catheter draining urine directly from the kidney - had no physician orders for routine care during their initial admission. The tube was observed without proper dressing or securement, contributing to its eventual dislodgement and requiring hospital transfer.
Temperature measurements of heating surfaces throughout the facility revealed dangerous conditions, with radiator covers reaching 157.8 degrees Fahrenheit - well above the 125-degree maximum safe temperature. These superheated surfaces were accessible to residents, including those with dementia and wandering behaviors who might accidentally lean against them.
Staffing documentation revealed systematic shortages across all shifts and units. Multiple staff members reported being unable to provide basic care due to insufficient personnel. During night shifts, some units operated with only two aides for 38 residents. The facility's own minimum staffing policy required 3.5 hours of care per resident daily, with specific ratios of licensed nurses to residents, but interviews and observations confirmed these standards were not being met.
A resident requiring dialysis three times weekly had no post-treatment monitoring orders, and staff were not assessing the dialysis access site for bleeding or infection upon return from treatments. A resident with an indwelling urinary catheter pulled it out on their first day of admission, but medical providers were never notified, leaving the resident without appropriate urinary management for over a week.
The state's inspection team declared an Immediate Jeopardy situation on March 12, 2025, for the aspiration supervision failures, requiring emergency corrective action. The facility implemented new protocols including separate tray delivery for residents on aspiration precautions, mandatory staff education with post-tests, and revised supervision procedures. A second Immediate Jeopardy was declared on April 23, 2025, related to the systemic staffing failures affecting all residents in the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Shore Winds, L L C from 2025-05-09 including all violations, facility responses, and corrective action plans.
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