Low grade for staffing at Water's Edge nursing home, where living woman was pronounced dead 

Water’s Edge Rehab and Nursing Center at Port Jefferson, which made headlines this month when a woman pronounced dead there was found later to be breathing at a funeral home, received the lowest possible rating for staffing by the federal Centers for Medicare & Medicaid Services, records show. 

Experts said the agency's rating indicates a negative impact on the quality of care provided to residents.

CMS, which established a rating system to help consumers compare nursing homes, gives the 120-bed nursing home a three-star overall ranking out of five for categories that also include health inspections and quality measures. But Water's Edge received only one star for staffing levels.

The agency points to data showing that registered nurses at Water's Edge spend fewer hours on weekends with residents than the state average. Turnover rates among all nurses there exceed the state average, while registered nurses leave the facility at rates nearly double New York's average, data shows.

Richard Mollot, executive director of the Long Term Care Community Coalition, an advocacy group for nursing home residents, said staffing is the most important criteria when evaluating a nursing home.

"When you see that a nursing home is not investing in its staffing, it tends to go hand-in-hand with them not putting [money] into other things such as cleanliness and food service," Mollot said. "The other things that are important to a resident's clinical and psychosocial well-being."

Interviews with residents or loved ones

Newsday interviewed current and former residents of Waters Edge, or their loved ones, after Suffolk County police said the nursing home declared dead an 82-year-old resident who later was found to be alive at a Miller Place funeral home. The State Health Department and the New York State Attorney General’s Office said they are investigating the incident.

The interviews showed the resident and family member perspective on the impact of short staffing. It can, they told Newsday, lead to stretches in which a resident says his basic grooming needs, such as bathing and teeth brushing, can go unattended, or in which accidents are not immediately reported to family members.

Kevin Gallo, 66, of Commack, who was paralyzed from the chest down following surgery while on vacation in Germany four years ago, was admitted to Water’s Edge first in 2020, and then again in 2021, hoping to receive specialized treatment that could restore his quality of life. But Gallo said the care he’s received at Water’s Edge has degraded him physically and emotionally.

His complaints include:

• A roommate who remained in the bed next to him dead for over for six hours, despite pleas to remove him.
• The loss of heat and hot water on Feb. 4, the coldest day of the year.
• Going nearly two weeks without a shave or shower, in part because of the lack of clean pads for the Hoyer lift needed to get him out of bed.
• The frequent absence of clean sheets, pillow cases or blankets.
• Stage-four bed sores.

“It’s a miserable situation,” Gallo said, adding that there is not enough staff to care for his needs.

In a written response, Water's Edge denied the complaints from Gallo and others. The home says that residents have never been left beside a dead person for an extended period of time; that patients are offered individualized care plans that include their showering and personal care preferences; that linens, bedding and toiletry items are made readily available; and that many physically compromised patients arrive with large and uncomfortable bedsores, which is common in the industry.

Water's Edge added that the HVAC system required servicing on Feb. 4 but that the building's temperature never fell below 74 degrees and the issue was resolved quickly.

"We take pride in the services that we provide to our patients, staff, and families," Water's Edge said in a statement. "The recent incident involving a patient being sent to the funeral home has become sensationalized, and unfortunately, has brought torment among our community.

"It is important to note that when this patient was deemed deceased, all proper protocols were followed, including several medical professionals confirming the death of the patient, in addition to the licensed funeral director arriving and also confirming the death of the patient, before the licensed funeral director transporting the patient to the funeral home." 

Higher level of complaints

Water's Edge was recently named by U.S. News & World Report as one of the state’s 38 best nursing homes. The facility has a three-star rating out of five from the state — which uses different criteria than CMS — with high marks for quality of life and preventive care and lower scores for resident safety and resident status, which includes topics such as changes in weight and the ability to move independently. 

State records show Water’s Edge has received $22,000 in fines from the health department during the past decade for violations such as failing to properly investigate accidents or promptly notifying family members when a resident was hospitalized.

Newsday reported last week that since 2019, Water’s Edge has received 14 citations from the state — less than the state average and none that resulted in “actual harm or immediate jeopardy” of residents, records show.

The facility has received 91 complaints from residents or family members during that same period, well exceeding the state average, the data shows.

Robert Svoboda of Wading River said he was so upset with the care that Water's Edge provided to his wife, Jane, who was admitted last year after having trouble walking, that he removed her after five weeks and filed a complaint with the health department. A copy of the health department's response to Svoboda, acknowledging receipt of the complaint, was provided to Newsday.

Svoboda said his wife would often go weeks without receiving a shower and failed to receive regular physical therapy. He said he was not immediately notified when she fell.

"It’s all about the owners not maintaining the proper staffing ratio of nurses, nursing assistants and aides to patients — which is regulated by New York law," he said. "Having daily consistency in the number of direct staff … makes all the difference in overall patient care."

Randy Stewart of Babylon said he's also been troubled about the care that his 82-year-old mother, Rosemary Stewart, who has early onset dementia, has received at Water's Edge.

Stewart said it took staff seven hours to notify him about a recent fall. Other days, he said, he has observed that his mother fails to receive all of her meals or her diaper is not changed regularly. 

"The conditions there are absolutely horrible," Stewart said, adding that he believes the problems stem from inadequate staffing.

In response, Water's Edge reiterated that residents have individualized care plans that include their showering preferences and that family members are encouraged to meet with their team to address any concerns.

"We stand behind our staff and mission statement to provide unprecedented levels of care," the nursing home said in a statement.

Barbara Ann Comuniello, 44, of Deer Park, who has been a resident of Water's Edge for eight months as she convalesces from a multiple sclerosis attack, credits the staff for her improving health.

"The physical therapy department is so good," she said. "They got my arms straight and had me lifting weights with my hand. I must say I've been in other places where the care hasn't been as good. What happened [with the funeral home] was unbelievable. But it happened. But this place is not bad."

Staffing concerns statewide

State officials recently said they'll soon 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 daily staffing levels equal to 3.5 hours of care per resident daily by a certified nurse aide, registered professional nurse, licensed practical nurse or nurse aide.

Michael Balboni, a former state senator from Nassau County who now serves as executive director of the Greater New York Health Care Facilities Association, a trade group that represents nursing homes, said long-term care facilities have long had difficulty attracting qualified staff. Low wages, combined with the risks posed by the pandemic, only magnified those problems, he said.

"The staffing issues were prevalent before COVID and have now become exacerbated," Balboni said, adding that most nurses can earn higher wages working in hospitals than in nursing homes. "This is a huge struggle for the workforce."

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.