Port Jefferson nursing home that pronounced breathing woman dead had prior violations

The Port Jefferson nursing home that pronounced a resident dead Saturday, only to be discovered alive at a Miller Place funeral home, has received $22,000 in fines from the State Health Department in the past decade for a range of safety and health violations, records show.

The violations include failing to properly investigate accidents or to promptly notify family members when a resident was hospitalized, according to records.

Since 2019, Water's Edge Rehab & Nursing Center at Port Jefferson has received 14 citations from the state — less than the state average and none that resulted in “actual harm or immediate jeopardy” of residents, Health Department records show.

But the 120-bed facility has received 91 complaints from residents or family members during that same time period, well exceeding the state average, state data shows.

On Saturday at 11:15 a.m., an unidentified 82-year-old woman was pronounced dead at Water's Edge and was taken more than two hours later to O.B. Davis Funeral Home in Miller Place, "where it was determined she was breathing," Suffolk police said. She was taken to a hospital for treatment, said police who did not provide an update on the case Monday.

The incident is being investigated by the State Health Department, which confirmed the investigation into whether the facility failed to meet state or federal requirements, but declined to comment further as the probe is ongoing. 

"This is an awful situation that has caused unnecessary trauma for the impacted resident and her loved ones," the office of State Attorney General Letitia James, which is also investigating, said in a statement. "The Office of the Attorney General is looking into the incident."

A message left at Water's Edge Monday was not returned while the funeral home declined to comment "out of respect for the privacy and confidentiality" of its customers.

State Health Department records show a mixed record for Water's Edge.

The facility has a three star rating out of five, with high marks for quality of life and preventive care and lower scores for resident safety and resident status.

Nonetheless, U.S. News & World Report last month named Water's Edge as one the state's 38 best nursing homes for 2022-2023.

Since June 2012, Water's Edge has been fined five times by the Health Department, ranging from $2,000 to $10,000, records show.

In January 2022, the facility was fined $2,000 after a November 2021 inspection in which a housekeeper was observed transporting a resident in a wheelchair in the hallway, changing a soiled mop head and then entering a residents’ a resident’s room without first changing her gloves or washing her hands.

In March 2021, the facility was fined $4,000 after a January 2021 inspection for resuming construction on an occupied COVID-19 unit, or an adjacent unit, without notifying the department, as required by state regulation, records show.

The facility’s largest fine in the past decade — $10,000 in January 2016 — came after a July 2013 inspection and is described in records only as failing to provide adequate supervision to prevent accidents.”

On two occasions during the past four years, the department cited Water's Edge for violations but declined to issue fines. 

In February 2022, inspectors issued a host of citations, including failing to document a resident who had fallen on the floor; family members not immediately notified when a loved one was sent to a hospital and a resident who did not receive immediate care for an open wound which later developed into a stage-three pressure ulcer, records show.

In August 2019, the facility was cited for unnecessarily providing a resident with anti-anxiety medication and not ensuring that a different resident was dressed in his own clothes — he was in a hospital gown — for lunch, department records show.

Water's Edge is not the only facility recently to prematurely declare a resident deceased.

An Iowa Alzheimer's Special Care Center was fined $10,000 last week after declaring one of its residents dead and transferring her to a funeral home, where she was found gasping for air in a body bag.

Similar cases of individuals in the morgue or funeral home who were actually still alive have occurred in recent years in Michigan, India, Mexico and South Africa.

Mike Lanotte, executive director and chief executive of the New York State Funeral Directors Association called the Water's Edge incident "very rare" and said it's the "first occurrence we are aware of in New York State."