Every finding on record at Shore View Nursing & Rehabilitation Center

Based on observation, interviews, and record review conducted during an abbreviated survey (incident # 651587), the facility failed to ensure that a resident was free from physical abuse. This was evident in one (1), (Resident #1) out of four (4) residents reviewed and sampled for abuse. Specifically, on 06/20/2025 between 12:10 PM and 12:15 PM, Resident #1's adult child reported that Resident #1's right thumb was bleeding. Resident #1 stated that during an eye examination on 06/20/2025, Ophthalmologist #1 (the consulting ophthalmologist) bit their right thumb. Resident #1 was examined by Registered Nurse #1 a skin opening was seen on the anterior side of Resident #1's right thumb. There was a small amount of blood seen, and a bruise on the posterior side of the right thumb. Resident #1 was transferred to the hospital for an evaluation and returned to the facility on [DATE] at 7:05 PM with a discharge diagnosis and treatment for a human bite. Ophthalmologist #1 was escorted out of the facility by New York State Law enforcement, arrested, and charged.The findings are: The facility's Resident Rights and Organizational Ethics Policies titled Abuse /Neglect/Misappropriation/Exploitation and Mistreatment dated 10/2022, documented on page 2 under Abuse Prohibition that the facility shall not use or permit verbal, mental, sexual, or physical abuse or other mistreatment or neglect. The policy documented that the prohibition extends to everyone, including residents, staff, consultants, volunteers, and staff of other agencies serving the residents, family members, legal guardians, friends, or other individuals. Resident #1 was admitted to the facility with diagnoses of non-traumatic subarachnoid hemorrhage and Diabetes Mellitus. The Minimum Data Set (a resident assessment tool) dated 4/24/2025 documented that Resident #1 had a Brief Interview for Mental Status and had intact cognition. The assessment documented Resident #1 required substantial to moderate assistance with bed mobility, transfers, and eating. The Facility's Accident Report, completed by Registered Nurse #2, the Assistant Director of Nursing, dated 06/20/2025, documented that Resident #1 had a head-to-toe assessment done. There was a skin opening to the right thumb measuring 0.3 x 1 x 0.2 cm on the right anterior thumb with minimal bleeding and a small superficial skin bruise on the posterior area of the thumb with intact skin. There were no changes in the range of motion of the hand. Resident #1 complained of pain, with a score of three (3) out of ten (10). Tylenol for pain was administered. The Registered Nurse Supervisor #3 and the Registered Nurse Practitioner #3 were informed. The Facility Summary of Investigation dated 06/25/2025 concluded that the injury was a human bite, but not intentional, but accidental. The staff followed the facility protocol, and there was no psychological or emotional harm to any of the residents involved. Resident #1 was referred to the psychologist and to the social worker for follow-up. The incident was reported to the Department of Health, law enforcement, and the Office of Professional Medical Conduct. The facility's Health Status Notes written by Registered Nurse #1 dated 06/20/2025 to 06/29/2025 were reviewed and documented on 06/20/2025 at about 12:10 PM, Resident #1 's adult child informed Registered nurse #1 who assessed Resident #1 's skin and noted an opening 0.3 cm x 1 cm x 0.2 cm on the right anterior thumb with minimal bleeding and small superficial skin bruises on posterior area of the thumb with intact skin was observed. There were no changes in the range of motion to the arm. The Nurse Supervisor and Nurse Practitioner #1 were informed immediately. Orders for cleaning the wound, medicating for pain (level 3/10 on right thumb), and to transfer Resident #1 to the hospital emergency room for further evaluation were received. Resident #1's adult child was at the bedside and agreed with the plan of care. The Hospital Discharge Home Instructions dated 06/20/2025, were reviewed. The Discharge Diagnosis was Human Bite. The discharge Instructions were Augmentin (antibiotic for infections) 875 milligrams to be given twice daily for five (5) days. The vaccine for tetanus, diphtheria, and pertussis was administered in the Emergency room. The skin integrity care plan initiated on 06/20/2025 documented the alleged incident of a human bite. The interventions include monitoring for infection. During an interview on 07/14/2025 at 11:45 AM, Resident #1, translated from Russian to English by the Registered Nurse Supervisor #1 stated 06/20/2025, they felt uncomfortable during the eye examination when pressure from the ophthalmology lenses was being applied. Resident #1 pushed the doctor with their hands, and the doctor pulled their mask down and bit their right thumb. Resident #1stated they called their adult child. During a telephone interview on 7/15/2025 at 11:13 AM, the accused, Ophthalmologist #1, stated State of New York had brought a lawsuit against them and they have been instructed by their attorneys to say nothing to anyone. The Ophthalmologist #1 documented on an investigative statement dated 06/20/2024, the Ophthalmologist #1 denied biting the Resident #1. During a telephone interview on 8/18/2025 at 3:18 PM, Registered Nurse #1 stated they were the charge nurse on the day shift on 06/20/2025. Registered Nurse #1 stated they saw the accused Ophthalmologist #1 on the floor about 12Noon when the Doctor came into the dayroom and asked whether they (Registered Nurse #1) could translate into Russian for a resident. At about the same time, Resident #1's adult child called to inform that Resident #1 was bitten and the finger was bleeding. Stated they do not recall whether the resident's child stated the Doctor bit the resident's finger. Resident #1 stated the doctor put in eye drops and was checking their eyes with the machine, and they (Resident #1) asked the Doctor to stop, when they (Resident #1) pushed the doctor's hand, the doctor bit their finger. There were no teeth marks, and the wound was from near the top of the thumb toward the first joint. There was small bleeding, the posterior side (palm side) had a vertical bruise with intact skin. During a telephone interview on 7/14/2025 at 4:04 PM, the nurse practitioner stated there were no teeth marks observed, but after seeing the skin marks and based on the Resident #1's statement, it was assumed the two skin openings must be from a bite. Stated the underside of the thumb was slightly discolored, and the area has healed. During a telephone interview on 8/15/2025 at 1:04 PM, the Director of Nursing stated that the ophthalmologist was an independent contractor hired by the corporation and not an employee of the nursing home, and has worked over ten years in the facility with no complaints. Also stated that the paperwork for consultants was done by the corporate office and not by the nursing home administration. 10 NYCRR 415.4(b)

Based on record review and interviews conducted during the Recertification Survey from 2/9/2022 to 2/16/2022, the facility did not ensure, to the extent practicable, that residents/resident representatives were involved in developing the comprehensive care plan and making decisions about their care. Specifically, the facility did not ensure that residents and resident representatives were afforded the opportunity to participate in the Comprehensive Care Plan (CCP) meeting. This was evident for 2 of 3 residents reviewed for Participation in Care Planning out of a sample of 38 residents. (Resident #40 and #62) The findings are: The facility policy and procedure titled Care Planning Progress dated 11/21 documented under section Procedure 5) Resident and/or designated representative will be informed of scheduled Care Plan Meetings, including the suggested date and time by the Social Services Department. The resident and/or designated representative will be invited to the meeting by phone call, in-person or written invitation. The invitation will be documented within the EMR and/or a copy of the written invitation maintained by the Social Services Department.10) The resident has the right to participate in establishing the expected goals and outcome of care, the type, amount, frequency and duration of care and any other factors related to the plan of care. 1. Resident # 40 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS dated [DATE] documented Resident # 40 was rarely/never understood others or made self understood, had short and long-term memory problems, and cognitive skills for daily decision making was severely impaired. It also documented Resident # 40 participated in assessment, and the family representative did not participate. On 02/09/22 at 12:36 PM, family representative was interviewed and stated they were not invited to care plan meeting and was not sure when was the last time they were invited to care plan meeting. Family representative also stated they made decisions for Resident # 40. The social worker progress note dated 3/26/2021 documented family was invited to care plan meeting on 3/30/2021. There was no documented evidence that Resident # 40 or representative had been invited to participate in the quarterly care plan meetings on 6/1/2021 and 8/24/2021. There was an invitation letter dated 11/15/2021 that was mailed to family representative for quarterly care plan meeting on 11/23/2021. The Comprehensive Care Plan Meeting signing sheet for Resident # 40 documented family representative attended the annual care plan meeting on 3/30/2021 but not the quarterly ones on 6/1/2021, 8/24/2021, and 11/23/2021. It also documented Resident # 40 did not attend any of the care plan meetings. On 02/15/22 at 04:15 PM, family representative was interviewed again and stated they received a lot of calls and letters from the facility. Family representative confirmed they received the letter of invitation to care plan meeting scheduled on 11/23/2021. 2. Resident #62 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS dated [DATE] documented Resident # 62 had severely impaired cognition. It also documented Resident # 62 participated in the assessment while the family representative did not. On 02/09/22 at 02:33 PM, Resident # 62 was interviewed and stated family representative and themselves were not invited to any care plan meeting. The Social worker note dated 6/3/2021 documented family was invited to attend annual care plan meeting on 6/8/2021. There was an invitation letter dated 11/22/2021 mailed to family representative for quarterly care plan meeting on 11/30/2021. There was no documented evidence that family representative and/or Resident # 62 was invited to quarterly care plan meeting on 3/9/2021 and 9/9/2021. The Comprehensive Care Plan Meeting signing sheet for Resident # 62 documented Resident # 62 and family representative did not attend the meetings on 3/9/2021, 6/8/2021, 9/9/2021, and 11/30/2021 On 02/15/22 at 03:44 PM, family representative was interviewed and stated they received the letter and call for invitation to care plan meeting scheduled on 11/30/2021. Family representative also stated they did not remember if they received the call or letter for other care plan meetings in 2021. On 02/14/22 at 03:11 PM, MDS Nurse (MDSN) was interviewed and stated the residents had care meetings for Admission, Annual, Quarterly, Significant Change, and As Needed. MDSN also stated MDS assessor, RN supervisor, Dietitian, Social Worker, Rehab Director, Recreation Director, CNA (Certified Nursing Assistant), resident and/or family representative attended the care plan meeting. MDSN further stated MDS department set up the care plan meeting schedule and Social Worker (SW) was responsible to invite resident and/or family representative at least 48 hours in advance by calling and the SW had to document the care plan meeting invitation in social worker note. On 02/14/22 at 03:34 PM, Director of Social Work (DSW) was interviewed and stated the care plan meeting was for Admission, Annual, Quarterly, Significant Change and As Needed. DSW also stated MDS assessor, RN supervisor, Dietitian, SW, Rehab Director, Recreation Director, CNA, resident and/or family representative attended the care plan meeting. DSW stated the SW invited family representative to care plan meeting by mail or by call a week in advance and documented the invitation in the social worker note. DSW also stated they did not invite Resident # 40 and/or family representative to the quarterly care plan meetings on 6/1/2021 and 8/24/2021; Resident # 62 and/or family representative to the quarterly care plan meetings on 3/9/2021 and 9/9/2021 because there was no significant change in Resident # 40 and Resident # 62's health status or care plan. DSW further stated the two quarterly care plan meetings for Resident # 40 and Resident # 62 were held amongst interdisciplinary team only. On 02/15/22 at 02:20 PM, Social Work Consultant (SWC) was interviewed and stated they recognized the importance of inviting resident and/or family representative to quarterly care plan meeting after their sister facility had the survey from the NYSDOH survey at the end of [DATE]. SWC stated they started inviting resident and/or family representative to quarterly care plan meeting on 11/8/2021. SWC also stated they revised the care plan meeting policy on 1/6/2022 after the plan of correction for the sister facility was accepted by NYSDOH in [DATE]. SWC further stated they revised SW note to indicate if resident and/or family representative was invited to care plan meeting and provided the in-service to SW on 1/24/2022 for Quarterly Care Plan - Policy update. SWC stated the resident and/or family representative were invited to care plan meeting by phone call, in-person or written invitation. SWC also stated they made copy of the invitation letter and kept the copy in the file in SW department and SW documented in SW note for invitation through phone call or in-person. Corrections taken for the past non-compliance: 1. Residents/representatives were invited to quarterly care plan meeting starting 11/8/21 2. QA Department audited to ensure all the residents/representatives due for quarterly care meeting in [DATE] were invited and continue the audit in [DATE]. 3. Revised the facility policy & procedure titled Care Planning Process with effective date 1/22 to include MDS will complete a Care Plan Review Meeting note to indicate the participation and/or attendance of the resident and/or designated representative for all meetings. 4. In-service for the topic Quarterly Care Plan - Policy Update was provided to all social workers on 1/24/22. 5. SW Social Work Assessment - V4 note was revised on 1/24/2022 to add the question for care plan invitation before the care plan meeting. 415.11(c)(2)(i-iii)

Based on observation, record review and staff interviews during the recertification survey, the facility did not ensure that food was served under sanitary conditions. Specifically, during a dining observation conducted on the 4th, the unit CNA (Certified Nurse Assistant) was observed touching two resident sandwiches, the inner surfaces of cups and container lids with her bare hands, wiping her hands on the back of her pants and picking up plate covers that fell on to the floor and replacing them on a cart without performing hand hygiene. Additionally, during follow-up observations, the 2nd floor CNA was observed touching the resident's bread with her bare hands and continuing on with serving other resident trays without performing hand hygiene. This was evident during observations conducted for the Dining Observation Task. (Unit 2 & 4). The findings are: On 9/21/2017 at 12:42:01 PM, a lunch observation was conducted on the 4th floor and the following observed: The CNA opened the plastic wrapper of a resident sandwich and touched the sandwich with her bare hands. When the resident stated that she wanted an alternate sandwich, the CNA retrieved another sandwich, opened the clear wrapping and used her bare hands to pull the sandwich apart. Additionally, the CNA picked up plate covers that fell on to the floor, replaced them on a cart and proceeded to distribute trays and open up food items without performing hand hygiene. The CNA also wiped her hands on the back of her pants and touched the inner surfaces of cups and soup container lids with her bare hands. On 9/25/17 at 1:03 PM, the second floor dining service was observed. CNA #2 was observed opening the plastic wrapper of the residents bread with her bare hands. The CNA then placed the lunch tray in the pantry area and disposed of the food wrappers in the garbage and proceeded with serving other resident trays without washing or sanitizing her hands. On 9/25/2017 at 11:56 AM, a 4th floor CNA was interviewed and stated that before and after I serve food, I wash my hands. When I open the plastic bread wrappers, I am not supposed to touch the bread with my bare hands. If a lid cover falls on the floor, after I pick it up, I wash my hands. After picking up anything from the floor, hand washing should be done. This is done to prevent bacteria from being transmitted from the floor to the hands and food. The RN (Registered Nurse) Charge Nurse was interviewed on 9/25/2017 at 12:04 PM. The RN stated that staff are supposed to perform hand hygiene before, during and after serving food as well as whenever picking up items from the floor. As far as food handling is concerned, gloves should be worn to prevent direct contact with the food item. If you touch your uniform, hand washing should be done to prevent cross contamination. The RN Inservice Coordinator/ Infection Control Nurse was interviewed on 9/25/2017 at 12:18:13 PM. The staff are taught that when they enter the dining room, hand washing is performed. Touching resident food with the bare hands is never acceptable. If they touch anything from the floor, hair, face or articles of clothing, hand washing is indicated. The CNA (who displayed the safe food handling and infection control breaches) works for an agency. All the agency CNA's are given the same inservice training as the facility staff and I conduct ongoing audits of staff performance. This CNA was recently audited and no issues were identified. On 9/25/17 at 1:33 PM, CNA #2 was interviewed and stated that she started work at the facility one month ago and received infection control in-service training on hand washing. The training included hand washing when first entering the dining room and before serving meal trays. The CNA further stated that she did not know that she was not supposed to touch food items with her bare hands. 415.14(h)

Based on record review and staff interviews, the facility did not ensure that a resident clinical record was complete and accurately documented. Specifically, a resident with doctor orders for nutritional supplements (Glucerna Shake and Liquid Protein Supplement) were not transcribed. (Resident #315). The findings are: Resident #315 is a [AGE] year old with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Review of Medication Administration Records (MAR) dated date of 5/19/16 documented discontinuance of the LPS SF (sugar free) 30 ml PO QD and Glucerna Shake 8 oz PO TID. Review of Medication Administration Records from 5/19/16 to 6/30/16 revealed no documented evidence that the supplements were administered. The Certified Nursing Assistant Accountability Record (CNAAR) for June 2016 did not document intake of Glucerna Shake supplement. On 6/28/16 at 9:39 AM, the Registered Nurse (RN) stated that the the nurse is responsible for entering in orders and the Doctor or the Nurse Practitioner (NP) signs off on the orders. The RN then stated nutritional supplements (Glucerna Shake and LPS) are documented on the MARS. On 6/28/16 at 3:46 PM, the Licensed Practical Nurse (LPN) stated that the doctor puts in orders and the nurse reviews them. The LPN further stated that she didn't think to question that the supplements were missing in the MAR because the resident has always been getting it. She further stated that she doesn't always check the doctor orders against the MARS everyday. On 6/30/16 at 10:50 AM, the Director of Nursing (DON) stated that nurses are responsible for checking the doctor's orders with the MAR, and administer medications or supplement. Nurses are trained upon hire. She further stated that since the nurses check the MAR daily, they should've caught the error. 415.22(a)(1-4)

Based on observation and staff interview during the recertification survey, it was determined that the facility did not ensure that housekeeping services were provided to maintain a sanitary and orderly interior. Reference is made to a stained water fountain, missing baseboard, peeling wall paint. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The Findings are: During the initial tour on the Recertification Survey conducted on 12/19/11 and 12/20/11 the following were observed: 1)The water fountain located on the 3rd floor near room 328, was observed with brownish stains around the rim. 2) A four(4) foot section of baseboard was missing near the medication room on the 5th floor. 3) Old shower room on the 5th floor was observed with a broken wall. Three inch stone was loosely held in place. 4) Dayroom on the 7th floor was observed to have at least a foot of wood paneling peeling off near the radiator. 5)Inside the corridor near the soiled utility area, on the 8th floor, baseboard in the corner was observed broken and loose. 6) Base of the corridor wall for the training facility on the 9th floor was observed with a two inch breakage of sheet rock (loose gravels). 7)Inside the rehab kitchen located on the 10th floor, a three foot section of the wall was observed with peeling/bubbling paint. In an interview with the maintenance director at various times on 12/19/11 and 12/20/11 he emphasized that all the above stated concerns will be corrected. 10 NYCRR 415.29

Based on observation and staff interviews, the facility did not ensure that resident's bathroom/shower room were maintain as evidenced by missing and stained tiles. This was evident for 2 of 8 resident care units (5th and 6th floors). This resulted in no actual harm with potential for more than minimal harm The findings are: 1) During an initial tour of the facility's 5th floor on 12/15/10 at approximately 10:00 AM, the hallway "training" bathroom was observed with missing wall tiles above the sink. There was also an area approximately 6 inches x 4 inches of brown stains on the tile next to the bathroom sink. The nurse who accompanied the surveyor on the tour was immediately interviewed and stated that the missing tile and brown stains were from the soap dispenser that had been replaced but the wall had not been repaired. 2) During the initial tour of the facility's 6th floor on 12/15/10 at approximately 11:00 AM, the hallway shower room was observed with missing tiles above the sink. The nurse on the tour stated that she was not aware that the tiles were missing. 415.5(h)(2)

Based on observation and staff interview, the facility did not ensure that infection control practices were maintained. Specifically, resident care items were stored in the soiled utility infectious waste room. This was evident for 2 of 8 units (Units #7 and Unit #8). This resulted in no actual harm with potential for more than minimal harm. The findings are: 1) During the initial tour of the 7th floor on 12/15/10 at 10:22 AM, the following items were observed being stored in the cabinet of the soiled utility infectious waste room: 14 Foley catheter bags, 1 small box of KCI Wound Vac pads, 2 boxes of catheter tubing, 1 bag containing clean basins, and 1 bag containing clean urinals. The LPN (Licensed Practical Nurse) was immediately interviewed and stated that she stored the supplies in the cabinet because she was following the labels on the shelves. She stated that she would remove the supplies. The RN (Registered Nurse) Supervisor was interviewed on 12/15/10 at 10:27 AM and stated that clean items should be stored in the medication room, and the items will be removed. 2) During the initial tour of the 8th floor on 12/15/10 at 11:00am, the following items were observed being stored in the cabinet of the soiled utility infectious waste room: 7 bedpans, 4 urinals, and 5 basins. The LPN was immediately interviewed and stated that supplies are kept on the 4th floor or given directly to the residents. She further stated that someone must have put the extra supplies there instead of returning them to the 4th floor supply storage. 415.19(a)(1-3)

Based on observation, record review and staff interview, the facility did not ensure that nursing assistant demonstrated competency with bathing a resident. This was evident for 1 of 30 sampled residents (#5). This resulted in no actual harm with potential for more than minimal harm The finding is: Resident #5 has resided in the facility since 10/21/10 with [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment dated [DATE] documented that the resident was continent of bowel and bladder and had been treated for [REDACTED]. Further review of the resident's record revealed that she was treated for [REDACTED]. The record also documented a urine culture result dated 12/14 /10 that was positive for E-coli in the resident's urine. A bed bath observation was conducted on 12/17/10 at 10:50 AM. The CNA (certified nursing assistant) was observed using a single washcloth to clean the resident including the perineal area. The resident was washed in a back and forth motion with the genital area wiped from back to front. The resident was also observed with toenails of both feet thick and long. The CNA was interviewed on 12/17/10 at 11 AM and stated that she knew to wash the resident from front to back and should have replaced the washcloth to ensure a clean procedure. The CNA further stated that she thought the technique used was okay as long as she avoided touching the resident's anus. The supervising RN (registered nurse) was interviewed on 12/17/10 at 11:05 AM and stated that the CNA had been taught the right thing and was sometimes assigned as a mentor to new CNA's due to her having received special training. The RN was asked about the process for obtaining toenail care for this resident. She stated that the condition of the toenails should be reported to the nurse by the CNA and then a consult to the Podiatrist can be generated if the nails require cutting. She further stated that she cannot recall being informed that the resident had long nails. The CNA was again interviewed on 12/20/10 at 12:10 PM and stated that the extra training received was on Dementia care of the Geriatric population and she was not provided any classes on incontinence care in the past year. The CNA was also asked about the resident's toenails and stated that she is required to tell the nurse if the resident's toenails appear discolored or long but did not recall telling anyone about it. 415.26(c)(1)(iv)

Based on observation, record review and interview the facility did not ensure that entries in a resident's clinical record was legible. This was evident for 1 of 30 sampled residents (#5) This resulted in no actual harm with potential for more than minimal harm The finding is: Resident #5 has resided in the facility since 10/21/09 with [DIAGNOSES REDACTED]. The resident was observed during care on 12/17/10 at 10:50 AM with thick elongated toenails extending over the tips of all 10 toes. The supervising RN (registered nurse ) was interviewed on 12/20/10 at 10:20 AM and was asked about the process for obtaining toenail care for this resident. She stated that the condition of the toenails is reported to the nurse by the CNA and then a consult to the Podiatrist is generated if the nails require cutting. Review of the clinical records revealed that the resident was seen on 12/1/2009 and received debridement of the toenails. A "report of consultation " dated 11/8/10 was presented to the SA surveyor as the latest documented visit by the podiatrist for this resident. The consult was not legible and had been co-signed by the resident's primary physician. The resident's physician was interviewed on 12/20/10 at 10:50 AM and stated that he signed the consult as he was aware the resident had no recommendations as she had no foot problems. The Podiatrist was interviewed on 12/20/10 at approximately 11:00 AM and stated that she believed that the resident refused nail care at the time of the last visit. The Podiatrist was provided with a faxed copy of the documentation and attempted to decipher same with much difficulty. The RN was again interviewed on 12/20/10 at 11:15 AM and stated that she was not aware that the resident refused care as this had not been communicated by the podiatrist and the notes were not legible. 415.22(a)(1-4)