A 56-year-old resident of a Southampton nursing home with Alzheimer’s was left alone in her room partially dressed in October 2022 when an emergency drew nearby staff to another room.

That's when a nursing home aide sneaked into the resident’s room and sexually assaulted the nonverbal woman for several minutes — an attack that was only halted when a nurse’s assistant entered and then quickly exited the room, according to an inspection report from the New York State Health Department.

The Hamptons Center for Rehabilitation and Nursing received a $10,000 fine from the state for failing to protect the resident, along with a federal penalty of more than $40,000.

And it's not alone.

About one quarter of all Long Island nursing homes received penalties from the state in 2023 for a host of violations, ranging from sexual assault and physical violence to a failure to change personal protective gear or to follow proper medication protocol, a Newsday investigation found. The fines, according to state records, are up slightly from one year earlier, although nearly half of those penalties were for the minimum amount of $2,000.

Richard Mollot, executive director of the Long Term Care Community Coalition, an advocacy group for nursing home residents, said the findings reflect an industry with minimal state oversight that continues to prioritize profit over patient care.

“Far too many nursing homes, particularly those in New York, continue to operate with grossly substandard staffing, which results in decreased resident monitoring, an increased use of agency staff and greater strain on nursing staff — all of which can exacerbate the risk to residents of sexual violence and other abuse,” Mollot said. “More than ever in my career, I am hearing of operators who flagrantly disregard resident safeguards. This is largely due to [state Department of Health] oversight becoming even more lax in recent years and providers knowing that they can get away with pretty much anything.”

Nursing home fine amounts declining

Records show 20 Long Island nursing homes — about one-fourth of the region’s 79 largely private facilities — received a combined $148,000 in fines from the state Department of Health in 2023, ranging from $2,000 to $36,000 for a litany of deficiencies that inspectors said jeopardized public health and violated guidelines.

Brookside Multicare Nursing Center in Smithtown and Garden Care Center in Franklin Square were fined twice, while all the others were fined once. The figures reflect fines administered in 2023, even if the violations occurred in previous years.

“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,” the agency told Newsday in a statement. “Per federal and State Public Health Law, nursing homes are responsible for protecting residents’ rights — including freedom from any type of maltreatment — and a maximum fine of $10,000 is permitted for violations that directly result in serious physical harm.”

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 larger amounts for multiple individual violations over several months, officials said.

For example, Brookside Multicare Nursing Center received fines of both $6,000 and $36,000. The smaller fine was for “multiple deficiencies” found during a Nov. 2, 2022, inspection. State officials said the larger fine was for a “failure to keep sufficient PPE in stock. The fine reflects citations for multiple individual violations over several months.”

Last year, inspectors handed down seven fines of $10,000 or more, compared with nine in 2022, six in 2021, three in 2020 and 11 in 2019, documents show.

In 2022, state inspectors handed down $144,250 in combined fines to 20 Long Island nursing homes, records show. Those figures were down from $208,500 in fines to 26 Long Island nursing homes in 2021, largely for COVID-19-related violations. In 2020, the department fined 12 Long Island nursing homes a total of $144,000.

“The findings further reflect that, even when there is a penalty, the penalty tends to be very low,” Mollot said. “For the nursing homeowners in New York, this is not even a slap on the wrist.”

Federal data from the U.S. Centers for Medicare and Medicaid Services (CMS) shows that, on average, nursing homes nationwide were fined $38,059 each during the past three years.

New York, meanwhile, averaged $12,775 in fines per nursing home during the same period — a figure that includes facilities that received no penalties during those three years. That’s the 46th-lowest total among the 50 states, ahead of only Arkansas, Alabama, Maine and Arizona, CMS records show.

CMS, which directed questions about nursing home fines to the state Department of Health, sets guidelines for states on how to impose penalties on facilities.

Medicare can impose its own penalties on a nursing home when there’s a serious health or fire safety citation, or if the facility fails to correct a citation for a long period of time.

Stephen Hanse, president and chief executive of the New York State Health Facilities Association, which represents the nursing home industry, cautioned against reading too much into monetary fines.

“The safety and health of residents and staff is the top priority for long-term care providers in New York,” Hanse said. “We are, and have been, committed to preventing these incidents. We fully support accountability to ensure the safety and well-being of our residents. It is also true that looking only at fines provides a narrow view of any situation. When we focus solely on punishing providers with fines, this does not help the residents and often fails to address the underlying issues.

“We support a collaborative, shared responsibility between providers and regulators to do what is best for the residents and effectively remedy identified issues,” Hanse said.

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‘I lost my mind’

The most serious allegation leveled against a Long Island nursing home involved an alleged sexual assault at the Hamptons Center for Rehabilitation and Nursing in Southampton.

The alleged victim, identified by her daughter, Stacy Smith, of Sound Beach, as a now 58-year-old woman with Alzheimer’s, had been a resident of the 280-bed facility for more than seven years at the time of the incident.

Newsday is not identifying the alleged victim at the request of family members.

During the late afternoon of Oct. 30, 2022, a "code blue," indicating a resident was found unconscious, was called on another unit, sending much of the nursing staff to the patient in need, according to an inspection report from the state Department of Health.

Nearly 20 minutes later, a recreational aide, later identified by police as Isaiah Quaron James, 34, of Mastic Beach, an 11-year employee of the facility, was seen on video surveillance entering the alleged victim’s room, records show. The woman had been left in the room wearing only a blouse and underwear with no pants, surveyors wrote.

Two minutes later, a certified nurse’s assistant entered the room and found James on the bed behind the woman with his pants down and appearing to have sexual intercourse with her, the report said.

The nurse’s assistant quickly exited the room and did not return for three minutes, at which point James already had left the area and had a brief interaction with another resident, records show. Nursing home staff then waited nearly 90 minutes before calling authorities while the alleged victim, who is nonverbal, was taken to a hospital for an evaluation, inspectors said.

Smith said she broke down when she received word of the alleged assault from the nursing director.

“I lost my mind on the phone,” Smith told Newsday. “To me, one of the worst things that could happen is me losing my mom. And that, I don’t think, will ever compare to somebody calling me to say my mom was violated. … I hope it never ever happens to anybody ever again.”

The Hamptons Center did not respond to multiple requests for comment.

In an interview with the facility’s nursing director, James said: “I know it looks bad,” but suggested he was just lying in bed with the resident while sending a text message, inspectors said.

James was arrested by Southampton Village police detectives and charged with first-degree attempted rape, first-degree attempted sexual abuse. first-degree criminal sexual act and first-degree endangering the welfare of an incompetent or physically disabled person.

On March 12, he pleaded guilty to attempted sexual abuse and endangering the welfare of an incompetent or physically disabled person. He is expected to be sentenced May 8.

George Duncan, James’ Islip Terrace-based defense attorney, declined to comment.

State inspectors fined the Hamptons Center $10,000 for the incident, while federal officials added a $40,034 fine, records show.

Brett Leitner, a Melville-based attorney representing Smith in a civil suit against the nursing home, James and facility owner Bent Philipson, attributed the incident, in part, to cost-cutting measures.

“They don’t have enough staff because staff is the largest line item of their expense sheet,” Leitner said. “If they had more staff, something like this could have been prevented. When the entire staff went to another unit for the code blue, it just created this opportunity for [James].”

Philipson is a longtime nursing home magnate who had amassed by 2020 — along with family members — interests in 163 facilities across 18 states, including Cold Spring Hills Center for Nursing and Rehabilitation in Woodbury, Long Island’s second-largest nursing home.

In 2022, State Attorney General Letitia James filed suit, alleging the owners and management of Cold Spring Hills diverted more than $22.6 million in Medicaid and Medicare funds for residents’ care by using a fraudulent network of a dozen companies to conceal upfront profit taking. Last month, a Nassau judge ruled Cold Spring Hills’ ownership must provide more than $2 million in restitution to the facility and install an independent health care monitor to oversee patient care.

Attorneys for Cold Spring Hills and Philipson did not respond to requests for comment.

Smith, meanwhile, said she made the difficult choice to keep her mother, who does not appear to have a recollection of the incident, at the Hamptons Center.

“What little she expressed talking-wise is not there anymore,” Smith said. “So the people that she does know there she’s so familiar with. This is her home for nine years. She doesn’t know anywhere else.”

‘A slap on the wrist’

Diane Garnett speaks with Newsday in March at her home in Central Islip.

Sunrise Manor Center for Nursing and Rehabilitation in Bay Shore was fined $4,000 by the state for its response to an allegation of sexual assault against a now 26-year-old former resident who had been admitted with an anoxic brain injury months earlier, according to a state inspection report and Diane Garnett, 61, of Central Islip, the alleged victim’s mother.

On Dec. 10, 2022, the resident told her family that a male licensed practical nurse had asked her to perform oral sex on him one day earlier and proceeded to grope her breast and vaginal area, inspectors said.

The resident’s family reported the incident to the facility’s administrator, but the nurse, who denied the allegations, continued to work at the facility with access to the resident, records show. Sunrise Manor, meanwhile, failed to promptly notify the state Department of Health or local authorities of the alleged assault, surveyors said.

The nursing home administrator told health inspectors they reviewed video surveillance and determined “there was no sexual, or any inappropriate touching or physical contact. The administrator stated the allegation was not reported to [the Department of Health] or the police because they had no finding that abuse occurred.”

Garnett, who said her daughter experiences confusion and some short-term memory loss, said she believed the allegation and filed a report with Suffolk County police. No arrest has been made. The case remains open with the department's Third Squad, authorities said.

In December, Garnett filed a lawsuit against Sunrise Manor and the nurse. Newsday is not identifying the nurse because he has not been criminally charged.

“They didn’t call police. They weren’t very cooperative and were not very helpful,” Garnett said of Sunrise Manor.

Nursing home officials did not respond to requests for comment.

State Department of Health spokeswoman Monica Pomeroy said the agency “does not have the legal authority to determine whether a matter should be prosecuted criminally, but refers every allegation of abuse received, including allegations of sexual assault, to the New York State Attorney General’s Office.”

The Attorney General's Office said it conducted a thorough investigation into the allegation and did not find sufficient evidence of criminal misconduct to bring charges.

The $4,000 fine issued by the state cites the facility’s failure to report the alleged abuse and to properly investigate the allegations.

“They’re guilty of gross negligence and professional misconduct,” Garnett said. “To be fined only $4,000 is a slap on the wrist, and it’s insulting.”

Garnett pulled her daughter from Sunrise Manor in September, and she now receives 24-hour-per-day care at home.

A threat and then violence

A cognitively impaired Hempstead nursing home resident suffered a non-displaced fracture to the wall of the left eye after being assaulted by another resident, inspectors said. The unidentified attacker had accused the cognitively impaired resident of stealing food, state inspectors said.

The Nov. 8, 2022, incident at the Mayfair Care Center led to a $10,000 fine from the state and an additional $9,770 fine by federal officials, records show.

State inspectors said the unidentified attacker had a history of behavioral problems dating back several months, including verbally and physically abusing staff, threatening employees, cursing, discussing the use of firearms and slamming the nursing station desk looking for narcotics.

The attacker also vocalized displeasure with a cognitively impaired resident who reportedly had a history of taking food from rooms, at one point threatening to “punch” that resident if it happened again, officials said. The victim, inspectors said, had been previously observed going into other rooms and eating from their food trays. The two residents lived across the hallway from each other.

Shortly thereafter, the resident followed through on the threat, entering the victim’s room and punching the victim repeatedly in the face, the report states.

The assault was broken up by a nurse who “jumped in between the two residents and screamed,” and the aggressor was removed from the area by police and later transferred out for 30 days “due to the resident being a danger to other residents,” the report states. The attacker no longer lives at Mayfair, records show.

A Mayfair physician had ordered nursing staff to check on the cognitively impaired resident every 15 minutes because of the victim's habit of wandering into other residents' rooms.

“There was no documented evidence provided by the facility that every 15-minute monitoring was being completed for [the victim],” inspectors wrote.

It is not clear if the resident was criminally charged.

Nursing homes 'don’t have enough staff’

Critics contend many of the most egregious nursing home violations can be attributed to low levels of staffing, poor employee pay and an inability to recruit a capable workforce — issues that were exacerbated during the COVID-19 pandemic and have yet to improve.

A report released last month by the American Health Care Association found 72% of nursing homes nationwide said their current workforce levels are lower than before the pandemic. The survey found 94% of facilities are finding it difficult to recruit new staff, with two-thirds citing a lack of interested or qualified candidates as an “extremely big obstacle.”

Experts have pointed to wages that are lower than other health care sectors, high turnover rates and the increased risk of infection during the pandemic, along with the vaccine mandates, as some of the reasons for the staffing shortage.

Priya Chidambaram, a senior policy manager with the nonprofit KFF’s Program on Medicaid and the Uninsured, said the average hours of daily care nursing home residents receive declined from 4.1 to 3.7 between 2015 and 2023.

“And at the same time that staffing levels have gone down, the share of facilities that were receiving serious citations increased,” Chidambaram said. “And so we’ve seen over time that deficiencies and staffing are related. And those really serious citations are more common in facilities don’t have enough staff.”

State officials hope to change that pattern.

A state law enacted in 2021 and that went into place earlier this year requires nursing homes to maintain daily staffing hours equal to 3.5 hours of care per resident per day by a certified nurse aide, licensed practical nurse or registered nurse. Of those 3.5 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.

State Health Commissioner Dr. James McDonald determined there is an acute labor shortage for registered nurses, licensed practical nurses and certified nurse aides in many regions of New York, including both Nassau and Suffolk. Nursing home trade groups have said up to 75% of all facilities have been unable to meet the staffing minimum requirements.

“The department is committed to ensuring that the compliance process minimizes the burden placed on facilities and guarantees that the department enforces the statutory staffing requirements in the most equitable and appropriate manner possible,” Pomeroy said in a statement.

Jim Clyne, chief executive of LeadingAge, a nursing home trade group that represents nonprofit and public facilities and which sued unsuccessfully to block implementation of the staffing law, said there are not enough candidates interested in positions to keep up with mandated staffing ratios.

“There’s a mandate on what those staffing ratios are supposed to be, and they’re in the process of coming up with penalties for places that don’t meet that ratio,” Clyne said. “But if you can’t find the staff, the only thing you can do is leave [nursing home] beds open.”

A separate law requires nursing homes to spend at least 70% of their revenue on resident-facing care — and 40% of those dollars on direct-care staff. Facilities could potentially avoid those fines if they take steps to limit their use of temporary agency staff.

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