A Brentwood nursing home resident with dementia found drinking from a brown bottle of liquid hair coloring dye.

A cognitively impaired Hempstead nursing home resident who wandered out of his facility before being returned by police and family members more than 20 hours later.

A Huntington nursing home resident with a history of suicidal ideation who leaped from his second-floor room, which had a window with a loose screw, onto the concrete below, suffering multiple fractures.

These are just some of the allegations against Long Island nursing homes cited and fined by state and federal regulators in 2024 a combined $661,210 for jeopardizing the health and safety of residents, according to inspection reports reviewed by Newsday.

Richard Mollot, executive director of the Long Term Care Community Coalition, an advocacy group for nursing home residents, said there are rules in place to protect the welfare of nursing home residents.

"Right now, the industry and its high-power lobbyists are working the halls in Albany, claiming that they need more public funds to provide better care," Mollot said. "But the fact is that Attorney General [Letitia] James’s investigations and our own studies have shown that substantial profits are being made while residents suffer. During the COVID pandemic, New York passed laws to improve nursing home accountability. It is time for those rules to be enforced."

Two of the largest fines issued last year were to nursing homes for failing to investigate abuse allegations. Medford Multicare Center for Living was issued nearly $140,000 in combined penalties for failing to ensure that sexual misconduct allegations against employees were reported and investigated. Cold Spring Hills Center for Nursing & Rehabilitation in Woodbury, meanwhile, was fined almost $118,000 for failing to report an allegation that an aide had roughly handled a resident.

Both facilities have been fined multiple times by state and federal regulators in recent years.

STORYWIDGET: liNURSING250411_table

Fines on the decline

In total, the state Health Department fined a dozen Long Island nursing homes — representing 15% of the region’s 79 largely privately owned facilities — a combined $108,000 for a collection of health and safety violations in 2024, records show.

By law, the state is prohibited from fining nursing homes more than $10,000 for a single violation but is permitted to issue penalties for multiple citations. The department issued nine $10,000 fines in 2024, records show.

In addition, the U.S. Centers for Medicare and Medicaid Services, whose fine amounts are not capped, separately fined 12 Long Island nursing homes a combined $553,210. That fine total is the most issued to Long Island nursing homes since at least 2015, according to a Newsday analysis.

Nine of the 12 nursing homes fined by the state last year were also penalized by CMS. An additional three nursing homes were fined by CMS but not penalized by the state, records show.

The $108,000 in fines for Long Island nursing homes was the lowest amount collected by the state since $52,000 in penalties was issued in 2018, according to a Newsday analysis.

By comparison, in 2023, 20 nursing homes were fined a combined $148,000 by the state Health Department; 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.

In a statement, the state Health Department said a declining number of fines collected in a single year does not indicate reduced agency oversight. The department contends the figure, for example, could indicate that nursing homes have made sustained progress in addressing past violations.

"Ensuring all nursing home residents receive proper care is a priority of the New York State Department of Health," said Monica Pomeroy, an agency spokeswoman. "Per federal and state public health law, nursing homes are responsible for protecting residents’ rights, including freedom from any type of maltreatment."

CMS data shows that, on average, federal nursing homes nationwide were fined $37,649 each during the past three years.

Nursing homes in New York, meanwhile, averaged $18,110 in fines during that same period, including facilities that did not receive any penalty, ranking 40th of all states nationwide, CMS 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.

Stephen Hanse, president and chief executive of the New York State Health Facilities Association, which represents the nursing home industry, said inspections have increased in frequency and stringency since the pandemic.

A decrease in fines, he said, indicates that nursing homes are becoming more compliant with public health laws.

"I think it's a function of the nursing homes coming out of COVID really prepared and battle-worn in terms of dealing with lots of issues," Hanse said.

‘You can’t drink that’

Maria Regina Rehabilitation and Nursing in Brentwood April 24, 2025

One of the most serious incidents cited last year involved a resident with dementia at Maria Regina Rehabilitation and Nursing in Brentwood who was found on Dec. 19, 2023, sitting in their reclining wheelchair drinking from a brown bottle labeled Wella ColorCharm blond hair dye, according to state inspectors.

The hair coloring box had been left unattended at the nurses' station by an aide after another resident did not show up to a beauty parlor appointment, inspectors wrote.

A certified nursing assistant heard the resident with dementia calling out for water and saw the bottle on their tray, before stating, "You can’t drink that," the report stated.

A nursing supervisor found the resident’s tongue and lips swollen and a doctor immediately administered steroids, records show. The resident was taken to South Shore University Hospital in Bay Shore for treatment.

The department fined Maria Regina, which did not respond to requests for comment, $10,000, while CMS penalized the nursing home an additional $8,512, records show.

During an April 12, 2024, interview with state inspectors, a Maria Regina administrator conceded the hair dye should have been properly secured and that storage policies have since been revised.

The charge nurse on duty at the time of the incident, the administrator said, was disciplined and no longer works at Maria Regina.

Gone for 20 hours

Hempstead Park Nursing Home. Hempstead April 25, 2025

At Hempstead Park Nursing Home, a cognitively impaired resident with non-Alzheimer's dementia walked through the front doors of the facility and into the 41-degree weather outside, state investigators said.

The resident was returned to the nursing home by police and family more than 20 hours later.

The incident began at 4:54 p.m. on Feb. 19, 2024, when the resident, who staff were supposed to monitor every 15 minutes because of a history of wandering off, walked through the main entrance of the nursing home and past the security guard on duty, video surveillance reviewed by the state showed.

The guard, who was not aware the individual was a resident, was seen shutting the alarm after it went off and then returning to security desk, investigators said.

Nursing home officials discovered the resident’s absence almost 90 minutes later and began searching the premises and calling police. A certified nurse aide told investigators that an earlier visual check was not conducted "because the unit was busy that night," inspectors wrote.

The nursing director told state officials the guard should have checked with a supervisor before disabling the alarm and that a binder at the security desk has pictures of all residents at risk of wandering off.

The resident was returned to the facility on Feb. 20 shortly before 1 p.m., records show.

During a March 13 interview, the resident told state inspectors "they walked to see mom."

Hempstead Park, which did not respond to requests for comment, was fined $2,000 by the state and $15,445 by CMS, records show.

‘I don’t want to live anymore’

Pine Forest Center for Rehabilitation and Healthcare in Huntington April 24, 2025

The bedroom windows at Pine Forest Center for Rehabilitation and Healthcare in Huntington are not supposed to open more than 6 inches, for residents’ safety.

But a loose screw on a window track allowed a resident with a history of suicidal tendencies to fully open the window of his second-story room and leap to the concrete 13 feet below, according to state inspectors.

Nurses at Pine Forest were expected to check on the resident, who had a history of wandering off, every 15 minutes, inspectors said.

The resident, who was found lying on their back outside, was taken to a hospital and diagnosed with multiple fractures of the spine, left ribs, pelvis and shoulder, records show.

The resident told investigators they "jumped out because I don't want to live anymore. I did not tell anyone. I almost died."

The state fined Pine Forest, which did not respond to requests for comment, $10,000. CMS has not fined the facility for the incident.

Medication error

Records show North Shore-LIJ Orzac Center for Rehabilitation in Valley Stream was fined $10,000 by the state and $41,574 by CMS after a resident received daily, lower-than-prescribed doses of two medications, experienced significant weight gain and died at a hospital shortly thereafter.

North Shore-LIJ Orzac Center for Rehabilitation in Valley Stream was fined $10,000 by the state and $41,574 by CMS after a resident received daily, lower-than-prescribed doses of two medications, experienced significant weight gain and died at a hospital shortly after, records show.

Nurses at the facility had physician's orders to notify them if the resident experienced weight gains of 3.3 pounds in a single day or 5.5 pounds during a 72-hour period.

But during a 12-day period leading to the resident's hospitalization, the resident gained nearly 8 pounds after being given less than their regular medication dosage, investigators wrote.

The resident, who began experiencing fluid buildup in their extremities and was having difficulty breathing, was transferred to an emergency room with heart failure and abnormally high potassium levels, records show. The resident died three days later.

The inspection report does not indicate if the medication error directly led to the resident's death.

"The issue was resolved after we took swift corrective action, reinforcing our existing safety protocols and implementing additional safeguards to prevent similar incidents in the future," said Joseph Kemp, a spokesman for Northwell Health, which operates the facility.

Abuse allegations

Medford Multicare Center for Living was issued the largest fine last year after investigators said it failed to ensure that allegations of sexual misconduct by staff members were reported and investigated.

The largest fine issued to a nursing home on Long Island last year by CMS was $134,713 to Medford Multicare Center for Living, which investigators said failed to ensure that allegations of sexual misconduct by staff members were reported and investigated. Medford, which did not respond to requests for comment, was also fined $4,000 by the state.

On March 30, 2024, a female resident with depression and bipolar disorder reported to a nurse that she'd been sexually abused by a certified nursing assistant and reported the same allegation to a different staff member days later, investigators found. The nursing assistant denied the allegations.

But inspectors said the allegations were never reported to the administrator or to police, and the CNA was allowed continued access to the resident.

A nurse told inspectors an investigation was not launched because the resident later informed them she made up the claim because she wanted the aide off their assignment. The resident, nurses said, had a history of "accusatory and physically abusive behaviors."

Two months after the alleged assault, Medford offered the resident counseling and a chance to file a police report. She declined both, inspectors said.

Cold Spring Hills Center for Nursing & Rehabilitation was fined for failing to report an incident in which a resident alleged a CNA roughly grabbed and turned their left hand while turning the resident to their right side, records show.

Cold Spring Hills Center for Nursing & Rehabilitation was fined $117,712 by CMS for failing to report a Jan. 21, 2024, incident in which a resident alleged a CNA roughly grabbed and turned their left hand while turning the resident to their right side, records show.

The resident reported the incident to a nurse, but the facility concluded that the resident and CNA's hands became accidentally entangled during the incident and "there was no reasonable cause to believe that any alleged abuse or mistreatment had occurred."

Cold Spring Hills, which is now under a new operator after facing years of financial difficulties, closure threats and state lawsuits, was also fined $6,000 by the state last year related to a series of 2020 infection control citations that occurred during the early stages of the pandemic. The nursing home did not respond to requests for comment.

'You're hurting me'

St. Catherine of Siena Nursing and Rehabilitation Care Center in Smithtown was fined for a pair of incidents in which a CNA was accused of being physically abusive to a resident.

St. Catherine of Siena Nursing and Rehabilitation Care Center in Smithtown was fined $4,000 by the state and $64,496 by CMS for a pair of March 7, 2024, incidents in which a CNA was accused of being physically abusive to a resident.

In one incident, the CNA slapped a resident on the leg with an open hand and roughly held the resident's wrist to the resident's mouth to prevent a biting incident, according to an aide who observed the incident, state inspectors said.

The aide later observed the same CNA abruptly removing a blanket from another resident and roughly pulling the resident's arms and legs during care, according to an inspection report.

The resident complained, "You're hurting me," but the CNA responded, "Well, you don't want to turn over," investigators wrote.

The CNA, who was terminated, told investigators "I barely hit" the resident and it was "softest thing in the whole wide world."

"St. Catherine of Siena Nursing & Rehabilitation regrets the incident involving a former employee," Lisa Greiner, a spokeswoman for Catholic Health Systems, which operates the nursing home, said in a statement. "Upon learning of the incident, the nursing home took immediate action, including separating the staff member from employment and thereafter agreed to resolve the matter with the regulatory agencies."

Carillon Nursing and Rehabilitation Center in Huntington was fined $10,000 by the state and $22,523 by CMS for failing to protect a resident from physical abuse.

Investigators said on Dec. 27, 2023, a resident reported they were struck several times in the chest by a CNA during a night shift.

The nursing assistant, inspectors said, wanted to change the bedsheets, which were soaked with urine, but the resident refused to get out of bed.

The resident suffered bruising to the chest and upper arm and the incident was reported to the health department and to Suffolk police. No arrests were made, police said.

The CNA was later terminated, inspectors said. Carillon did not respond to requests for comment.

The Hamlet Rehabilitation and Healthcare Center at Nesconset was fined $10,000 by the state and $43,610 by CMS after a resident recorded a CNA acting in a verbally and physically aggressive manner to them, inspectors said.

The resident, who had a history of repeatedly ringing the call bell, was confronted by a nursing assistant screaming, cursing and instructing them to stop being "belligerent," according to a 3-minute and 35-second video reviewed by investigators, the report said.

The nursing assistant, who was later terminated, was also seen on video swinging their hand wildly, "displaying signs of physical aggression," the report said.

Hamlet also received a second $10,000 fine from the state in 2024, records show, for failing to properly monitor a resident's bowel movements.

The resident, records show, was hospitalized and later died of septic shock related to stercoral perforation, a rare condition caused by the accumulation of impacted fecal material.

In a statement, the Hamlet said it is contesting the fines and that "we are proud of the care and careers provided to so many here at The Hamlet."

Staffing problems

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

For example, a November report by the Long Term Care Community Coalition found that New York nursing homes reported an average of 3.59 total nurse staff hours per resident daily — putting New York among the 10 lowest states in respect to average nurse staffing.

Meanwhile, a March 2024 report by the American Health Care Association found 72% of nursing homes nationwide said their workforce levels are lower than before the pandemic.

Irien Moawad, president of pharmacy services and compliance for Community Care Rx, which provides pharmaceuticals to nursing homes and other long-term care facilities, said staffing shortages, particularly among nurses, are the largest drivers for major health and safety violations.

"The staffing shortage is definitely a problem," Moawad said. "Not retaining good talent has been a problem, along with education and retraining staff."

A New York State law enacted in 2021 that went into place last year requires nursing homes to maintain daily staffing hours equal to 3½ hours of care per resident per day by a certified nurse aide, licensed practical nurse or registered nurse. Of those 3½ hours, at least 2.2 hours of care per resident daily must be provided by a certified nurse aide and at least 1.1 hours of care must be provided by a licensed nurse.

Penalties for failing to follow the staffing law could result in a $2,000 daily fine, although facilities could challenge the penalty if they prove that they made substantive attempts to boost staffing levels.

Hanse said more needs to be done to recruit young people for potential careers in long-term care and working in nursing homes.

"We're going to need more nursing homes," Hanse said. "Folks are getting older. The baby boomer population is really aging out right now. There are not enough nursing home beds. So the state needs to continue to invest in long-term care and recognize its critical role in the health care continuum."

With Arielle Martinez

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