Shore Winds Nursing: 11 Violations, Care Failures - NY

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.