Violations at Long Island nursing homes, including assaults, prompt more than $500,000 in fines

A Port Jefferson nursing home resident spiked a high fever and was experiencing a fast heart arrhythmia.

Shortly after 8 p.m. on Jan. 26, 2025, a nurse at the facility, Water’s Edge Rehab and Nursing Center at Port Jefferson ordered the resident be sent to the hospital for an emergency blood transfusion. The nurse’s supervisor, however, determined the resident would go to the hospital the following morning, according to a state Health Department inspection report.

By 2 a.m., the resident was dead, according to inspectors from the state, which fined Water’s Edge $10,000 for the incident.

More than seven months later, Water’s Edge, which did not respond to requests for comment, was fined almost $154,000 — the largest single fine issued to a Long Island nursing home last year — by the U.S. Centers for Medicare and Medicaid Services. The penalty came after a resident requiring the use of an oxygen tank to breathe went into respiratory distress and pleaded with a nearby nurse for air, records show.

The nurse determined the resident was "exaggerating," suffering from a panic attack, and would be given Xanax, an inspection report shows. Moments later, a supervisor noticed the resident’s oxygen tank was empty and ordered a new one, CMS reported.

The resident survived.

‘Horrifying’ incidents

The episodes are among the 18 citations issued for serious health and safety violations — including multiple allegations of physical or sexual abuse against residents at Long Island nursing homes — that generated $511,092 in fines by the state or federal government last year, records reviewed by Newsday show.

Richard Mollot, executive director of the Long Term Care Community Coalition, an advocacy group for nursing home residents, called the incidents "horrifying" and said they’re the "exact opposite" of the care that families expect when they place loved ones in a nursing home.

"The failures to address and report allegations of physical and sexual abuse signifies a number of serious failures, including failing to protect residents from harm, failure to support resident dignity, and failure to comply with legal and regulatory requirements for reporting both abuse and suspicion of a crime against a nursing home resident," Mollot said.

The state Health Department issued fines to nine Long Island nursing homes in 2025 — representing around 11% of the region’s 78 largely private facilities — for a combined $116,000. That’s the fewest number of Long Island nursing homes fined by the state since 2018, when the state penalized just four local facilities.

The $116,000 in penalties, however, exceeded the state’s 2024 total, when the Health Department issued $108,000 in fines to a dozen Long Island nursing homes.

By comparison, in 2023, 20 nursing homes were fined a combined $148,000 by the state; in 2022, 20 nursing homes were fined $144,250; in 2021, 26 nursing homes received fines totaling $208,500; and in 2020, 12 Long Island nursing homes were fined $144,000, records show.

Two of the nursing homes penalized by the state last year — Woodbury Heights Nursing and Rehabilitation Center (formerly known as Cold Spring Hills Center for Nursing and Rehabilitation) and San Simeon by the Sound Center for Nursing and Rehabilitation in Greenport — were fined twice by the Health Department, records show.

The Health Department described the fluctuating fine amounts as a reflection of the inspection process, its timing and the number and type of citations issued, adding that year-over-year trends have limited importance.

For example, a lower number of fines, officials said, could coincide with corrections to health and safety violations that have been made and sustained from the previous year. 

"Ensuring all nursing home residents receive proper care is a priority of the New York State Department of Health,"  department spokeswoman Marissa Crary said. "Per federal and state public health law, nursing homes are responsible for protecting residents’ rights, including freedom from any type of maltreatment. As regulator, the department is committed to holding nursing homes and their operators accountable for the quality of care they provide."

But John Dalli, a Mineola-based elder care attorney, said the department "continues to fail nursing home residents and their families in New York by its inconsistent and lackluster investigations of claims of neglect and abuse. Too often, the New York State Department of Health limits its investigations into resident falls and resident deaths to a single phone call to the facility where a supervisor and/or nursing director is interviewed and the matter closed after the conversation."

By law, the state is prohibited from fining nursing homes more than $10,000 for a single violation but is allowed to issue penalties for multiple citations.

In 2025, the department issued seven fines of $10,000 or more; nine such fines in 2024; seven in 2023; nine in 2022; six in 2021; and three in 2020, records show.

Federal fines also on the decline

The Centers for Medicare and Medicaid Services, whose fines are not capped, fined six Long Island nursing homes a combined $395,092, a more than 28% decline from one year earlier when they penalized 12 facilities a total of $553,210, the data shows.

Five of the nine nursing homes fined by the state were also penalized by CMS while one facility was fined by CMS but not by the state.

CMS data shows, on average, nursing homes nationwide were federally fined $32,637 each during the past three years, including facilities that did not receive any penalty.

Nursing homes in New York, meanwhile, averaged $22,640 in fines during that same period, ranking it 30th of all states nationwide, CMS data shows.

In 2025, 34% of nursing homes statewide were fined at least once, significantly fewer than the 53% fined at least once nationwide, according to Priya Chidambaram, a senior policy analyst with KFF's program on Medicaid and the uninsured. That puts New York’s ranking as fifth-lowest in the country, behind Alabama, Arizona, New Hampshire and Virginia, the data shows.

CMS, which did not respond to requests for comment on its fines of Long Island nursing homes, set guidelines for states on how to impose penalties on facilities.

The agency can impose its own penalties on a nursing home when there’s a serious health or fire safety citation, or if the facility fails to correct a citation of an extended period of time.

Michael Balboni, executive director of the Greater New York Health Care Facilities Association, which represents nursing homes statewide, said the declining number of nursing homes fined on Long Island reflects their improved compliance with state and federal guidelines.

"We always want to see the fines reduced, and we do believe there’s an effort on behalf of the nursing homes to try harder and provide better service," said Balboni, a former state senator from Nassau County. "Any fines need to be dealt with and taken into account, but we are pleased at the trend; certainly that it’s not going up."

Many of the nursing homes cited by investigators last year have faced scrutiny before.

For example, in 2023, Water’s Edge pronounced a resident dead, only for the 82-year-old woman to be discovered alive at a Miller Place funeral home. The woman died the following day.

The resident’s family have since filed suit against the nursing home.

Woodbury Heights, then known as Cold Spring Hills, has accumulated more than $600,000 in federal fines since 2021; was sued by the state attorney general’s office for fraud; threatened to shut down in 2024; later declared federal bankruptcy; and is now under new management.

‘Get out’

One of the most serious cases documented by both state and federal inspectors last year involved a resident with Alzheimer’s disease accused of sexually abusing three other residents at St. Johnland Nursing Center in Kings Park.

On the morning of Dec. 16, 2024, a nurse responded to a call for help from the dining room and observed a wheelchair-bound resident, who was waiting for breakfast, touching the genital area of another resident over their clothes, an inspection report stated.

When the nurse intervened and removed the victim, the offending resident was left unsupervised and began rubbing the genital area of a second resident inside their pants while also touching themself, the report said.

The nurse later conceded that the offender, who was transferred to a hospital for "aggressive behavior" but returned shortly thereafter, should have been moved away from the other residents, investigators wrote.

More than two months later, a St. Johnland nurse heard another resident yelling "get out," the report states. When the nurse entered the room, they found the bed linens pulled down, the resident’s pants pulled below the waist, and the same offender’s hands on the victim’s genital area, investigators found.

The identity and gender of the offender and victims — all three of whom also have Alzheimer’s — are not clear.

The nursing home acknowledged the offender was prone to verbally and sexually inappropriate behavior and was on every-30-minutes monitoring, inspectors wrote.

It was not immediately clear if the offending resident remains at St. Johnland or if a police report was filed. The facility did not respond to requests for comment.

The state fined the nursing home $30,000 — $10,000 for each incident — while CMS tacked on an additional $30,817 penalty, records show.

Struck twice in the head

Among the more frequently penalized Long Island nursing homes in recent years is A. Holly Patterson Extended Care Facility in Uniondale — part of a public-benefit corporation that also operates Nassau University Medical Center, a safety-net hospital in East Meadow whose oversight board was taken over by the state last year.

Last year, CMS fined A. Holly Patterson $111,014 for an incident in which a certified nursing assistant restrained a resident’s hands and struck them twice in the head, records show. The state also fined the nursing home $4,000 for failing to protect the resident and not immediately reporting the incident, records show.

The May 4, 2025, incident, which was recorded on surveillance video, was sparked when the victim was in the hallway sitting in a wheelchair outside of a resident’s room.

The video recorded the certified nursing assistant pointing their finger in the face of the victim, who responded by striking the hand of the certified nursing assistant twice, investigators wrote.

The CNA then struck the resident twice across the head and held both of the victim’s hands down toward the wheelchair, records show. A facility visitor observed the nursing assistant striking the resident.

Two additional nursing assistants were in the hallway at the time of the incident but denied seeing the incident, the inspectors wrote.

The resident was not injured and the CNA who struck the victim was terminated. The other two CNAs were suspended without pay, records show.

The nursing home did not respond to requests for comment.

Federal investigators last year also fined A. Holly Patterson $14,518 for a Jan. 10, 2025, incident in which a resident, who required two staffers for transfer from their wheelchair into the bed, was moved by a single nursing assistant, records show. 

During the transfer, the resident hit their left leg on the metal bed frame and suffered several broken bones, investigators wrote.

Aide accused of sexual abuse

San Simeon, another frequently cited facility, was hit with two state penalties in 2025, records show.

The facility was fined $4,000 for failing to investigate and report a December 2023 incident in which a CNA was accused of asking a resident to remove their clothes, touching them inappropriately and asking them to do a dance, an inspection report shows.

The nursing assistant, who denied the allegation, was allowed to continue with their regular duties.

Five days later, another resident reported the same CNA touched their thigh while in bed, called them "baby" and asked them to dinner in New York City, records show.

San Simeon staff told inspectors they did not document or investigate either allegation because they believed the claims were already being investigated, records show.

The CNA was eventually suspended and did not return to work, records show.

San Simeon officials did not respond to requests for comment.

Southold Town Police Chief Steven Grattan said the first allegation was closed after the claim was determined to be unfounded while the second did not reach the level of a criminal violation.

San Simeon was separately fined $2,000 by the state last year after surveyors found the facility’s hot water tested at nearly 128 degrees Fahrenheit, records show. State regulations stipulate that water heaters that service resident rooms, bathrooms and common areas not exceed 120 degrees. No one was injured.

‘I want to die’

While many of the nursing homes fined last year are frequent offenders, The Grand Pavilion for Rehabilitation and Nursing at Rockville Centre had not been penalized by the state in at least a decade.

But that ended after a January 2025 inspection during which investigators encountered a resident with a stage 3 pressure ulcer, also known as a bed sore, to the sacrum — a large triangular bone at the base of the spine.

The resident "was in their room and was heard from the hallway complaining in profane language that their buttocks hurt and saying, I want to die," the inspection report stated. 

There was no documented evidence the resident had been assessed for pain management nor any physicians’ orders for pain medication, records show.

Nursing home staff told investigators the resident, who was dependent on staff for bed mobility and transfers, had complained of pain since developing the pressure ulcer.

Grand Pavilion officials did not respond to requests for comment.

The state fined the facility $10,000 for the violation while CMS added a $60,401 penalty, records show.

Staffing remains a problem

Experts in elder care issues contend that many of the most egregious nursing home violations can be attributed to low staffing levels, both locally and nationwide.

For example, a report last month by the Long Term Care Community Coalition found 87% of nursing homes nationwide reported total nursing levels below the expected staffing necessary to meet basic clinical needs.

The average nursing home nationwide reported 3.90 hours per resident, per day of nursing staff, well below the 4.94 hours that is expected to meet their residents’ needs, the organization calculated.

New York nursing homes, meanwhile, ranked 45th nationwide in staffing adequacy, with an average of 3.57 total nursing staff hours per resident daily, the group reported.

All of the Long Island nursing homes cited by the state or federal government last year, Mollot said, are staffed below the levels needed to meet their residents’ basic needs.

"It is therefore no surprise that terrible things happened to vulnerable residents," Mollot said.

While staffing remains a "challenge," Balboni said, "the situation has gotten better on Long Island, which means more resources."

Complicating matters, the Trump administration in December repealed a Biden-era rule requiring nursing homes to provide residents with a minimum of 3.48 hours of nursing care per day — including at least 2.45 hours from a nurse's aide and 0.55 hours from a registered nurse.

The rule, which was intended to be phased in this year, also mandated that nursing homes participating in Medicare and Medicaid have at least one registered nurse on-site 24 hours a day.

Dalli, the Mineola elder care attorney, said the repeal, which was supported by elder care facilities and their trade groups, "sends the wrong message to nursing home owners who already, for the most part, place profits over people."