Records: Cold Spring Hills Center for Nursing & Rehabilitation fined more than $600G for jeopardizing resident safety 

The Woodbury nursing home state prosecutors sued last year for fraud has stacked up more than $600,000 in federal fines in three years, including what records show was among the biggest federal financial penalties issued nationwide last year for jeopardizing resident safety. 

The documents show a resident who went into respiratory distress at Cold Spring Hills Center for Nursing & Rehabilitation died in March while waiting for an ambulance after a nurse ignored a doctor's order to call 911.

They also reveal another resident at the private facility, Long Island's second-largest nursing home, suffered facial burns in February after smoking a cigarette while using a nasal cannula, a device that delivers extra oxygen through a tube.

Newsday obtained records on the health citations from the Centers for Medicare & Medicaid Services and the New York State Department of Health. They show CMS, a federal regulatory agency that provides health coverage to more than 160 million Americans, fined the facility a total of $182,095 in April after state officials uncovered both incidents during a March inspection.

Records also show that penalty to Cold Spring Hills followed a fine of more than $400,000 last summer, the 13th highest out of more than 9,300 penalties the federal agency meted out across the country in 2023.

Attorneys for Cold Spring Hills declined to comment. Edline Severe Joseph, the facility's administrator, didn't respond to requests for comment. 

Deadly wait for ambulance

The resident's death at Cold Spring Hills in March happened during a delay for emergency care that lasted more than an hour and a half, records show.

State inspectors wrote the ventilator-bound resident, whose name wasn't disclosed in records, was experiencing "respiratory distress," including a rapid heartbeat, fast breathing and excessive sweating.

But a nurse, whose name also wasn't disclosed, ignored a nursing home physician's order for the resident to immediately be transferred to a hospital and called for an nonemergency ambulance service instead of calling 911.

The service told Cold Spring Hills it would take two hours for an ambulance to arrive, inspectors wrote.

More than an hour after the initial diagnosis, the resident's family intervened and demanded a call to 911, the report said. Even then, the nurse waited another 20 minutes to make the call, leading to a 93-minute total delay in the arrival of EMS personnel, inspectors said. The resident died waiting for the ambulance.

The nurse, who told inspectors the resident was "stable" enough to wait for a nonemergency ambulance service, was fired, records show.

Richard Mollot, executive director of the Manhattan-based Long Term Care Community Coalition, an advocacy group for nursing home residents, called the March patient death "nothing short of horrifying." 

He added: "The fundamental purpose of a nursing home is to ensure the safety of our most vulnerable individuals. Instead, according to the state's report, facility staff displayed a gross indifference to their residents' well-being." 

Inspectors said the facility didn't have a written policy addressing "if or when Emergency Medical Services should be notified" but later established such a policy.

"It's astounding that this facility, after these and other significant failures to meet minimum standards, is just now developing a policy on when to call an ambulance," Mollot said. 

During the same March inspection, state health officials found a Cold Spring Hills resident "with a history of unsafe smoking" had suffered serious burns to his cheeks, nose and mustache a month earlier while smoking a cigarette in a courtyard unsupervised while on oxygen therapy. The records indicate the resident needed emergency room treatment for his injuries.

Wave of problems

The nursing home has faced a wave of problems in recent years, threatening its ability to stay open.

At the heart of the turmoil was a 2022 lawsuit from New York Attorney General Letitia James' office that argued the facility's owners neglected resident care and skirted state laws through a fraudulent business setup to enrich themselves.

In March, State Supreme Court Justice Lisa Cairo ordered the facility's owners to pay $2.65 million in restitution and in April appointed an independent health monitor to oversee resident care.

In the subsequent months, dozens of employees resigned after the facility eliminated its union-funded health care coverage, according to a report health monitor Lisa Wickens-Alteri issued this month.

In addition, the report said state regulatory agencies had approved a potential buyer for the facility, which was "at a critical point" with "growing staff concerns," and included some details about recent federal fines.

The potential buyer that has expressed interest in acquiring Cold Spring Hills, though there’s no deal at this point, has been officially approved by the state in its purchase of a different nursing home.

The most recent fine for $182,095 came less than a year after CMS fined Cold Spring Hills $408,105  last August, after state inspectors issued 40 health and safety code citations during a 10-day mandatory routine inspection.

Among findings last summer, health inspectors said the facility failed to ensure that one resident with serious bedsores received treatment and failed to ensure that another resident got required pain medication. Other violations included a lack of sufficient nursing staffing and residents with unapproved medication or not receiving physician-ordered wound treatment.

Records show Cold Spring Hills challenged its August fine — the second-largest penalty CMS issued to a New York nursing home in the last three years. CMS then reduced the penalty to $165,558.

CMS also imposed a 2½ -month "denial of payment" period on Cold Spring Hills, in which the government halts Medicare or Medicaid payments to a nursing home until citations are corrected. The federal agency lifted that period in January.

'A drop in the bucket'

Since June 2021, CMS has fined Cold Spring Hills a total of $614,177 — more than any nursing home on Long Island and second in the state to Bishop Rehabilitation and Nursing Center in Syracuse, which has a designation as one of the nation's poorest performing nursing homes.

John Dalli, a Mineola-based elder care attorney who has several negligence cases pending against Cold Spring Hills, said its owners view state and federal fines as the price of doing business.

"They're repeat offenders," Dalli said. "The fines they're receiving reflect that, although they've been admonished and been told they need to increase staffing and have more appropriate care plans in place, they haven't heeded any of those warnings. That's why you see these larger fines. But, in reality, that amount of money is a drop in the bucket to these guys."

Of the fines, CMS said in a statement that the agency is "committed to improving the quality of care and quality of life for all nursing home residents."

The agency said it can impose penalties "when there's a serious health or fire safety citation or if the nursing home fails to correct a citation for a long period of time."

Besides the two large fines, CMS fined Cold Spring Hills three other times in the last three years, records show.

In May 2022, CMS fined Cold Spring Hills $22,340 after staffers mistakenly believed a resident who stopped breathing had a "Do Not Resuscitate" order and failed to perform potentially lifesaving care. The resident died, Newsday previously reported. State health officials separately fined the nursing home $10,000, the maximum allowed for a single incident.

CMS also fined Cold Spring Hills $987 in January 2022 and $650 in November 2021 for failing to properly report information about COVID-19 cases.

Court records show the 588-bed nursing home now has 367 residents — down from 388 a month ago — needs massive physical repairs and saw the departure of 53 staffers, including 26 nurses, in the past month.

With Anastasia Valeeva

By Robert Brodsky

robert.brodsky@newsday.com@BrodskyRobert

Robert Brodsky is a breaking news reporter who has worked at Newsday since 2011. He is a Queens College and American University alum.