CPR failures, sexual abuse: Nursing home inspections reveal 'grotesque neglect,' insignificant fines, experts say
Nurses at a pair of Long Island nursing homes declined to provide potentially lifesaving CPR to two residents who were found unresponsive because of the mistaken belief that the patients, who were later declared dead, had “do not resuscitate” orders, according to State Health Department records.
The errors, which resulted in $10,000 fines apiece to Cold Spring Hills Center for Nursing and Rehabilitation in Woodbury and Central Island Healthcare in Plainview, were blamed on administrative confusion by staffers who falsely believed that the wrist- or armbands the residents were wearing indicated that a DNR was in place.
The incidents, which have not been previously reported, are among a series of disclosures outlined in Health Department inspection reports of Long Island nursing homes in 2022 obtained by Newsday. The state found:
- Two residents from Glengariff Rehabilitation and Healthcare Center in Glen Cove were sexually abused by a certified nursing assistant who told investigators that “God and angels” helped him provide care for residents.
- A resident at Gurwin Jewish Nursing and Rehabilitation Center in Commack was stripped naked and forced into a shower against the resident’s will, while that person was screaming for help.
- A. Holly Patterson Extended Care Facility in Uniondale failed to develop a comprehensive care plan for a resident with an extensive history of illicit drug use before the resident overdosed on heroin at the nursing home. The resident survived. A nursing home official called the case an "isolated" incident.
Richard Mollot, executive director of the Long Term Care Community Coalition, an advocacy group for nursing home residents, called the findings “horrific” and said they’re indicative of an industry that prioritizes profit over patient care with little oversight by the state.
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Twenty Long Island nursing homes received $144,250 in combined fines in 2022 from the State Health Department for deficiencies that inspectors said jeopardized public health and violated public health guidelines.
- The fines included two cases in which nursing home staff failed to provide potentially lifesaving care to residents who they erroneously believed had a "do not resuscitate" order in place. Neither resident had a DNR and both died.
- One Glen Cove nursing home was fined $10,000 after the state found a certified nursing assistant sexually abused two residents.
“We are seeing cases of just grotesque neglect,” Mollot said. “ … There is just a pattern of poor care and of low staffing that are going unaddressed. And even when we find that there are serious issues, the owners are allowed to continue operating.”
Nursing home industry officials contend the incidents, while rare, are the product of an overworked and underpaid workforce that is managing a growing number of residents in a difficult environment.
Records show that 20 Long Island nursing homes — or about a quarter of the region’s 79 largely private facilities — received $144,250 in combined fines, ranging from $250 to $24,000, from the Health Department in 2022 for a host of deficiencies that inspectors said jeopardized public health and violated public health guidelines. A. Holly Patterson and Medford Multicare Center for Living in Medford were fined twice, while all the others were fined once.
Although the maximum amount that a nursing home can be fined for a single citation under state law is $10,000, facilities can be fined for multiple violations from the same inspection.
Last year, inspectors handed down nine fines of $10,000 or more to Long Island nursing homes — compared with six in 2021, three in 2020 and 11 in 2019. One case is being criminally investigated, law enforcement officials said.
Comparatively, the Health Department issued $208,500 in fines to 26 Long Island nursing homes in 2021, largely for COVID-19-related violations such as a lack of masking or staff failing to frequently change personal protective equipment. In 2020, the department fined 12 Long Island nursing homes a total of $144,000, while in 2019 the state fined 12 facilities a total of $116,000, records show.
Last year, with the worst of the pandemic largely behind the state, nursing home inspections refocused on more general health and safety violations, with fines for COVID-19 violations representing just a fraction of the total amounts. In a statement, the department said it conducts rigorous oversight of nursing homes.
"Holding nursing homes and their operators accountable for the quality of care they provide is a top priority for the State Department of Health, and we remain as aggressive as possible in assessing the maximum fines permissible by law in every instance,” Health Department spokesman Cort Ruddy said in a statement.
Statewide, the department said it's issued more than $4.2 million in fines to 542 nursing homes since 2020, representing "only a portion of the total number of cases for which we are actively pursuing fines."
But critics of the state's monitoring of nursing homes contend that most operators view a $10,000 fine as the "cost of doing business."
“There’s absolutely no threat that anything the state will do is going to have a significant impact on them financially,” said John Dalli, a Mineola-based elder care attorney. “And until the fines mean something, it's like punishing murder with a maximum one- or two-year sentence.
"A $10,000 fine for violating someone's rights with respect to their choices about whether they want to be resuscitated or not is really sickening," he added. "That's the word I’d use. It's sickening.”
The U.S. Centers for Medicare and Medicaid Services, which directed questions about nursing home fines to the state Health Department, sets guidelines for states on how to impose penalties on nursing homes.
Priya Chidambaram, a senior policy analyst with the Kaiser Family Foundation's program on Medicaid and the uninsured, said federal data shows that the average nursing home nationwide is fined $33,000 annually. New York, meanwhile, averages $9,700 in fines, including those that received no penalties, per nursing home annually.
"So New York falls in the bottom fourth" of setting fines nationwide against nursing homes, Chidambaram said.
Cristina Crawford, spokeswoman for the American Health Care Association, a national trade group that represents the nursing home industry, said penalizing facilities does little to help make meaningful change in the industry.
"We fully support accountability to ensure the safety and well-being of our residents, but one challenge with [civil monetary penalties] is that they can take away precious resources from an already underfunded industry," Crawford said. "When fines are necessary and justified, they should be done equitably and in a timely fashion."
Assemb. Ron Kim (D-Queens), a critic of the state's oversight of nursing homes, said he supports allowing inspectors to potentially shutter facilities that have demonstrated repeated instances of gross negligence. But Kim said Gov. Kathy Hochul's administration has shown no appetite for increasing oversight of the industry.
"These incidents are absolutely shocking and the remedy was woefully subpar," Kim said. "We need to really hold these facilities accountable. We can't do that if the outcome is a slap on the wrist … These incidents are also a small glimpse of a larger trend that we're not able to actually oversee the system."
The Health Department, responding for the governor's office, said every nursing home complaint is reviewed and could potentially trigger unannounced on-site surveys as well as off-site record reviews.
"The department has several tools at its disposal to hold nursing home providers accountable and works closely with the Medicare and Medicaid Services to designate special focus facilities due to a persistent record of poor care," Ruddy wrote in a statement. Three nursing homes in the state are on the special focus list, none of which are on Long Island.
Deadly DNR confusion
Among the most serious lapses in health and safety standards cited in the inspection reports were a pair of separate but similar incidents at Cold Spring Hills and Central Island in which nurses erroneously believed residents who had stopped breathing had DNRs in place that would legally prevent them from providing potentially lifesaving care.
In both cases the resident died.
At Central Island, a certified nursing assistant was providing morning care to a newly admitted resident who later became unresponsive and had no pulse or respiration, the state found. A registered nurse who entered the room declined to initiate CPR because the resident was wearing a red armband — the nursing home’s identifier for a patient with a DNR order. The resident was declared dead at 11:40 a.m.
But the red armband had no relation to the facility's DNR system and was applied by a hospital before the resident’s admission to Central Island and was meant to warn about the patient's allergies.
The nursing staff never checked the physician’s orders, which indicated that the resident, whose name was not disclosed, had “full code” status, meaning that CPR should have been administered, the report said.
A second registered nurse told inspectors that staff intended to cut off the hospital armband but it became tangled in the resident’s chain bracelet while the resident was eating dinner. The nurse “intended to return to cut the red arm band … but got caught up with other emergencies,” the inspection report states.
Central Island did not respond to requests for comment.
Second CPR case, at Cold Spring Hills
A nearly identical mistake was made by a pair of nurses at Cold Spring Hills, Long Island’s second-largest nursing home.
On the morning of May 3, an unidentified resident, who was admitted with end-stage renal disease, anemia and colon cancer, was found unresponsive with no pulse. Nurses failed to check the resident’s advance directive status and decided against initiating CPR because they believed the resident had a DNR in place.
DNR orders at Cold Spring Hills were identified with an orange label on the spine of the resident’s medical records, an orange symbol in the resident’s electronic medical records, and an orange tab on the resident’s ID bracelet. The resident’s ID band had an orange tab, but the electronic medical records lacked the orange symbol, inspectors discovered.
A supervisor instructed the nurse to “follow the wishes of [the resident]” and not to initiate CPR. The resident was declared dead at 6:55 a.m.
The report does not explain why the resident had an orange tab on the bracelet.
The nurse and the supervisor were terminated and were reported to the state Education Department’s Office of the Professions.
Cold Spring Hills, which did not respond to requests for comment, later changed its ID band policy.
Mollot said the problems outlined in the inspection reports raise serious "red flags" about the type of care being provided at the two nursing homes.
"It pains me to say it," he said, "but I would be especially concerned about putting a loved one in a Long Island nursing home for an extended period."
Dalli is even more blunt.
"These mistakes are inexcusable. They're unacceptable," he said. "There's no possible excuse."
An unredacted copy of the Cold Spring Hills inspection report was included in a lawsuit brought in December against the nursing home by State Attorney General Letitia James.
The complaint alleges that the owners and operators of the facility neglected residents’ care and skirted state laws through a fraudulent business setup elaborately designed to enrich themselves. The operators profited by diverting $22.6 million in government funding from resident care and repeatedly cut staff, including in the weeks before the pandemic, leading to horrific end-of-life scenarios, the suit contends.
Residents sexually abused
The state inspection reports also found that Glengariff Rehabilitation "did not ensure residents' rights to be free from sexual abuse."
Two residents who had extensive mobility issues and required assistance with bathing alleged that a male certified nursing assistant stuck his finger in their rectum without their consent, at least on one occasion during a bed bath.
One resident said in an interview with Glengariff staff that he/she could not "face their family due to the shame of the incident," the report states. "[The resident] was observed during the interview crying with tears dripping from their cheeks and shaking … [The resident] was observed making a fist and waving their hands and stated, this should have not happened. [The resident] stated they are ashamed. [The resident] stated it was their fault this happened, and they should have protected themselves."
A second resident described to family experiencing a similar incident with the nursing assistant. A family member then notified Glengariff.
The nursing assistant admitted touching one of the victim's buttocks and rectum but denied it was sexual abuse.
He told inspectors that "God and Angels helped me taking care of residents and helped my days and nights go smooth, easy, and fast … God gave me a mission to help people. They had a special gift of knowledge to take care of people, and they can utilize it to assist residents."
The nursing assistant was terminated. The state Attorney General's Office, which declined to comment, and the Glen Cove Police Department launched a joint criminal investigation.
Glen Cove Police Lt. John Nagle said the investigation was initiated in March 2022 following a complaint by one of the victim's family members.
"The investigation is progressing, but I can't comment on it as it's an active investigation," Nagle said.
Glengariff, which did not respond to requests for comment, was fined $10,000 combined for both incidents.
At Gurwin, inspectors learned that two certified nursing assistants forced a resident who had declined to take a shower into the bath against the resident's will.
"The resident started to yell and then screamed rape, rape while [the resident was] fully dressed and in the hallway," the report states.
The nursing assistants undressed the resident, but when the shower had no hot water, transported the resident — wrapped in a bedsheet — to another shower room, again while the resident screamed "rape," the report states. The resident later told law enforcement there was no rape.
One of the nursing assistants told inspectors that the resident had refused three previous showers and that the aide "did not want to get blamed for not providing a shower to the resident."
The inspection report said the nursing assistant received counseling for failing to ensure the resident "was treated with respect and dignity and failing to ensure the resident's right to make choices about receiving a shower were respected."
Gurwin was not fined for the shower incident, but was fined a total of $10,000 for a pair of unrelated incidents in which residents were injured because of a lack of supervision by nursing home staff. One of the incidents, the report said, was not immediately reported to the Health Department as it was legally required to do.
A Gurwin spokesman declined to comment.
A resident with a history of both using and selling illicit drugs was admitted to A. Holly Patterson in 2021, but the facility failed to develop and implement an effective plan to address the resident's substance abuse disorder, inspection reports show.
In late 2021, the unidentified resident was found unresponsive at the Uniondale facility and treated at a hospital after a drug overdose, but no assessments or changes were made to the care plan when the resident returned to A. Holly Patterson.
Less than three months later, the resident, who previously had complained about depression and about being bored at the facility, was found unresponsive and was transferred to a hospital after an overdose on heroin, inspectors said. The narcotics, inspectors learned, were provided by a visitor.
The resident had been kicked out of a previous facility, the report said, for using and selling heroin and cocaine.
Nonetheless, a certified nursing assistant told inspectors that there were no instructions in place for monitoring the resident for substance abuse and that they were not aware of the resident's history of drug overdoses.
A. Holly Patterson was fined a total of $22,000 for its lapses in care related to the heroin overdose, reports show, along with another $2,000 for an incident in which it failed to properly isolate a COVID-19-positive resident.
"These civil citations were the result of two isolated situations that occurred last year and have been rectified," said Anthony Boutin, chief executive of the Nassau Health Care Corporation, which operates both A. Holly Patterson and Nassau University Medical Center in East Meadow. "One involved a unique patient situation, and the second was related to certain signage. AHP provides a high quality of care because of our constant practice reviews, staff education and operational improvements throughout the facility. Any issues identified were carefully reviewed and addressed to the satisfaction of federal and state authorities."
Four other Long Island facilities received fines of at least $10,000 in 2022, including Westhampton Care Center and Quantum Rehabilitation and Nursing in Middle Island.
At Westhampton, a resident dependent on two aides for bathing fell out of a shower chair when a nursing assistant attempted to perform the care without the assistance of a second staffer, the report said. The resident was transferred to a hospital with a subdural hematoma.
Westhampton, which did not respond to a request for comment, was fined $10,000 for the incident along with another $4,000 after facility staff failed to don personal protective equipment when entering the rooms of several residents who were being monitored for COVID-19, records show
At Quantum, staff administered only half the prescribed dosage of an anti-seizure medication to a resident over a more than two-week span, inspectors found. The resident was hospitalized with an undisclosed ailment. Quantum, which did not respond to requests for comment, was fined $10,000.
Understaffed and underpaid
For experts who have studied the nursing home industry for decades, the allegations outlined in the inspection reports are not surprising.
Michael Balboni, a former state senator from Nassau County who serves as the executive director of the Greater New York Health Care Facilities Association, which represents long-term care facilities and nursing homes, said the long-standing care problems plaguing many nursing homes can be linked to low staffing, poor staff pay and an inability to recruit a capable workforce — issues that were exacerbated during the pandemic.
State officials soon plan to begin enforcing a 2021 law establishing minimum staffing levels at nursing homes.
The bill, signed by former Gov. Andrew M. Cuomo, requires nursing homes to maintain staffing levels equal to 3.5 hours of care per resident daily by a certified nurse aide, registered professional nurse or licensed practical nurse.
Federal lawmakers, including U.S. Sen. Kirsten Gillibrand, have been pressing the Centers for Medicare & Medicaid Services also to create minimum staffing standards in nursing homes.
“There’s been no real investment in long-term care and therefore the starting salaries for certified nursing assistants have basically remained flat and have really approached minimum wage levels,” Balboni said. “Which means, why work in a nursing home when you can work in McDonald's and basically make comparable money and not have the responsibility of caring for somebody else.”
Dalli, who has brought dozens of lawsuits against nursing home operators, including many who were fined in 2022, points the finger at low staffing levels and employees who are poorly trained and undermanaged.
"Nursing homes continue to take in more people than they can care for," Dalli said. "And, because they're taking in so many people, and because their staffing is not increasing, you're just going to see more bad results. You're going to see more falls. You're going to see more bedsores. You're going to see more people who are not treated in accordance with their care plan."
How the nursing home inspection system works
- The state Health Department is supposed to conduct a certification survey on-site at least once per year to determine whether a facility meets the Medicare and Medicaid quality and performance standards. It can issue fines of up to $10,000 for violations that jeopardize public health or break public health guidelines
- Separately, surveys are also conducted by state inspectors due to complaints reported to the department, or incidents reported by the facility. Complaint Surveys focus on specifics of the incident, which can result in citations issued to the facility.
- In addition, inspectors conduct COVID-19 surveys with special focus on the infection-control practices in the facility.
- All nursing home inspections, officials said, are unannounced.
- Nursing homes are required to submit a written plan of correction to the department when deficiencies are cited. The department accepts or rejects the plan of correction based upon a review.
- New Yorkers with a complaint about a nursing home can contact the state’s Centralized Complaint Intake directly at 888-201-4563. All complaints are kept confidential, and at the conclusion of each investigation, the outcome is shared with the complainant.
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