The knifing happened the night of May 2, just inside the “smoking room” at Oceanview Manor, home to dozens of mentally ill adults in Coney Island, Brooklyn. A dispute between two residents had ended with one slashed on the neck and hand. Police officers, regulars at the address off Surf Avenue, soon arrived. The victim was taken to a hospital; the assailant was questioned, and he gave up the knife. No one was arrested.

Emergency responders were back at Oceanview Manor at least five times over the following week. On May 11, the city’s coroners were required when a man was discovered dead in Room 406. The arrival of the medical personnel set off a mix of curiosity and bickering among the home’s residents, some of whom did not like having the weekly movie interrupted. It took several hours before the resident was taken out in a body bag, but information about the death was scarce.

Three days later, shortly after dawn on Mother’s Day, Diane Jenkins, 57, was dead, as well. She had been at the home for just two weeks. Residents barely knew her. None knew how she’d died.

Homes such as Oceanview have been the subject of scandal and promised reform for years. Newspaper exposes and a federal lawsuit nearly two decades ago revealed that the homes, once envisioned as humane alternatives to New York’s troubled psychiatric hospitals, had effectively devolved into places of neglect and misery.

Conditions in some of the largest homes were unsanitary and dangerous. Residents were often exploited by the owners of the for-profit homes as well as by a variety of unscrupulous medical providers eager to bilk government health care programs. People incapable of giving their consent were forced into needless surgery. Podiatrists billed hundreds of thousands of dollars for doing little more than trimming toenails.

At last, in 2014, a federal judge in Brooklyn signed off on a plan that required New York state to improve the fortunes of adult home residents by moving thousands of them into supportive housing better integrated into the city’s neighborhoods. As well, limits were set on how many mentally ill people could stay in the remaining homes, an attempt to prevent the owners from simply repopulating the facilities with fresh residents consigned to the same conditions.

Today, Oceanview has taken on a distinctive role in the latest act of the legal saga surrounding the adult homes. Lawyers for the adult home industry have sued the state on behalf of a single former resident at Oceanview, a man who had taken advantage of the judge’s plan and moved into alternative housing, but who the lawyers say now wants to return. The man missed his friends and the conveniences of the Coney Island neighborhood, the lawyers argue. The lawyers succeeded in persuading a state judge to temporarily suspend the regulations the state had adopted as part of the federal case, including those governing how many mentally ill adults can reside in the homes at any time.

The federal judge, Nicholas Garaufis, did not react well to the industry’s lawsuit. At a hearing earlier this year, Garaufis portrayed the action as a ruse meant to more broadly challenge the regulations governing the operations of the homes that had been adopted by the state as part of his court-ordered settlement.

Lawyers for the homes have insisted they are interested only in gaining the single resident, identified only as John Doe, a return to the home he has come to miss.

The lawyers, who represent both the industry and the single former resident, filed an affidavit signed by John Doe as part of the lawsuit. He was 63 and suffered from a serious mental illness, the man said in the affidavit. He missed the hot meals at Oceanview and the ability to play basketball at a park nearby. He longed for the sense of security and community he enjoyed at Oceanview, he said.

“I desperately want to move back to Oceanview,” he said in the affidavit.

A ProPublica reporter spent parts of the last several weeks in and around Oceanview — meeting residents, talking with workers, interviewing police officers who respond to emergencies there. The facility, a five-story structure capable of housing 176 residents, sits in a largely desolate corner of Coney Island. To the right of the facility is a defunct employment agency. To its left is a fenced-off lot, crammed bumper-to-bumper with school buses. On the street out front, three large dumpsters double as bathrooms for residents who shuffle in and out of the home day and night, smoking cigarettes and drinking malt liquor.

Many residents appeared both ill and unkempt. The police ungently likened them to zombies. They beg for change. They eat from garbage cans. The staff, for their part, often appeared overmatched, treating residents with pity or hostility. One worker said she regularly got high to get through her shift.

Fire Department records obtained by ProPublica show roughly 130 calls from the home to firefighters or Emergency Medical Services in the last year. One such call required an “all-hands” response from the nearby stationhouse. The fire was listed as a suspected arson. Police officers told ProPublica they are called as often as two or three times a day, usually to escort residents to nearby psychiatric wards during a crisis.

Yet Oceanview, far from downsizing in the face of the state’s regulations, is actually expanding. Construction is underway, with a new section of the home being installed. The home, it turns out, is now taking in increasing numbers of residents who are not seriously mentally ill, but rather old and infirm, who get extra help through a state assisted living program. Several of the residents there under the assisted living program told ProPublica they had no idea they were entering a home that housed large numbers of the mentally ill. The state and federal government split the $1234-a-month rent for both sets of residents. Additional services are typically billed to Medicaid at a profit to the homes, according to critics.

Weeks ago, ProPublica filed a freedom of information request with the New York State Department of Health for recent inspection reports on Oceanview and other homes. The state has so far not produced the records. We also submitted questions concerning John Doe’s request to return and the residents at the home as part of the state’s assisted living program. We also asked if Oceanview had reported the recent deaths at the home as regulations require.

On Tuesday, a spokesman for the department sent a statement, but did not answer our questions. He cited “pending litigation” as one reason for the limited response.

“New York State has comprehensive regulations which prioritize the welfare of adult home residents,” the state said. “The Department of Health enforces these regulations, requires operators to implement plans of correction when noncompliance is identified, and assesses monetary penalties when necessary. As we have previously stated, the Department remains fully committed to both adult home residents and the terms of the settlement agreement.”

Oceanview, a for-profit operation, is owned and overseen by Lisa Vider. Documents and interviews indicate she inherited it from a relative named Joseph Rosenfeld, who died in 2009. The adult homes are typically owned by families or individuals, not by major chains, and they subsist on state and federal dollars.

Vider would not be interviewed when we called for comment. “Talk to my lawyer,” she said before hanging up.

Jeffrey Sherrin, a lawyer who has long represented the state’s adult homes, including Oceanview, said in an email that the residents who had died in recent weeks had died from natural causes.

“Oceanview has an elderly, sick population of people with complex medical and mental health conditions who generally have moved into the Home because they could not survive or cope in other living settings,” he said.

Sherrin would not answer more detailed questions about Oceanview’s operations or the case of John Doe, but he said comparing the current state of the homes with the scandalous conditions of years ago was false and unfair. He denied anyone had been stabbed at the home in recent weeks, despite police interviews and records that confirm the incident.

David Vargas, 56, is one of the forceful presences at Oceanview. He said he came to the home three years ago through a desperate combination of workplace injury, subsequent unemployment and naivete. When he could no longer afford his rent, he lost his apartment and landed in a nursing home, where he said he was then recruited by a contractor hired by Oceanview management to bring in new tenants.

His fellow residents refer to Vargas as their mayor or president, some with genuine respect, some with grumbling scorn. He sells them cigarettes and cigars. One recent morning he said he was owed $600. He keeps a ledger in a tattered notebook to track debts he is owed. He also keeps a pair of handcuffs dangling from his walker.

“It’s for intimidation,” he said.

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Throughout the years of scandal and litigation, many of the owners of the largest adult homes insisted they had been unfairly demonized. They claimed they had done the best they could to provide what the law required: room, board, housekeeping, supervision and personal care for their residents. Any shortcomings, they argued, were largely attributable to inadequate financial support from the government agencies overseeing them.

Judge Garaufis was never persuaded, and he ultimately held both the industry and its state overseers at the New York Department of Health responsible for the troubled state of the homes. In 2014, he established a formula for aggressively moving roughly 4,000 residents into more suitable living arrangements. The Department of Health had to make sure residents were assessed, and that those who wanted to move got relocated.

As part of the settlement, the state also adopted new regulations governing the homes. Those regulations contained two crucial requirements: One, that homes with 80 or more residents — at least a quarter of whom have some form of mental illness — not accept more residents with mental illness; two, that psychiatric hospitals not discharge patients to homes where at least 25 percent of residents are mentally ill. The regulations, to be sure, represented a threat to the financial model for the homes, many of which had come to house the mentally ill all but exclusively.

John Doe’s stated desire to return to Oceanview Manor gave the industry an opportunity to challenge those regulations. He said he had been relocated, but did not like the various new apartments he was sent to live in. The conditions were not great. He didn’t know anyone. He felt at risk.

And so in November 2016, Jeffrey Sherrin, a lawyer who has represented the adult home industry for decades, filed a lawsuit in state court in Albany, the state capital and home to the Department of Health. The lawsuit paints a fairly rosy portrait of Oceanview and homes like it, noting that they are tightly regulated by the Department of Health; that they provide meals that “meet strict nutritional guidelines,” and that they provide a variety of services to residents, including medication and recreational activities.

“I miss the support and services I received at Oceanview,” Doe said in a sworn affidavit filed as part of the lawsuit. “I cannot cook for myself and I have difficulty with cleaning my apartment and doing my laundry. I did not live like this when I used to live at Oceanview because they provided me with hot, good meals.”

The lawsuit faulted the regulations limiting the number of mentally ill residents at the adult homes for preventing John Doe from returning to Oceanview.

“Due to these new regulations, adult homes are being forced to deny people like petitioner with a mental illness access to the housing and services of adult homes,” it said.

The lawsuit sought to void the regulations. In a move that would enrage Garaufis, the state consented — failing to mention the federal settlement or to inform him.

At a hearing in his courtroom in March, Garafus lit into the industry and the state. He accused them of scheming to subvert his order to move residents out of the homes, noting that the state is woefully behind on its deadlines. He called a hearing on March 22, requiring the presence of the commissioner of health, the commissioner of mental health and the counsel to Gov. Andrew Cuomo. He castigated the lot of them: “I will not allow the kind of political, legal activity that is going on in this case behind my back and behind the backs of the plaintiffs to continue,” he said.

State lawyers scrambled to explain themselves. They said they never meant the Albany judge’s order staying the regulations to go beyond the case of the single man wishing to return to Oceanview.

In the weeks since, the state has promised to ask the Albany judge to lift her suspension of the regulations, and John Doe appears to be reconsidering his request to return to Oceanview.

But Sherrin, the lawyer for the industry, has pledged to continue to challenge the regulations in court. Last week, at a hearing before Garaufis, Sherrin filed a motion seeking to have the judge recuse himself, citing the judge’s wife’s work for a mental health advocacy organization. Garaufis said he’d long ago disclosed his wife’s work.

“I’m not my wife,” Garaufis said. “I do what I think is right. I follow the Constitution as I am sworn to do.”

Garaufis then suggested Sherrin may have his own ethical issues. He pointed out that Sherrin had somehow come to represent both adult home operators and adult home residents, parties whose interests may conflict. He asked Sherrin to comment on that in forthcoming papers.

Sherrin would not answer questions as he walked out of the courtroom.

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Online, Oceanview advertises itself as something of an urban paradise.

“Only steps away from the Coney Island famous boardwalk and beaches,” boasted one such ad on the nursing home website Caring.com. “Oceanview has beautiful ocean views that provide a calm and relaxing environment to all those who reside there.”

The first and only review of Oceanview on that same website offered a different perspective: “It was filthy, the people living there were unkept, dirty,” the review said. “The staff just sits around doing nothing. The nurses and receptionist were very rude. I would never put my love (sic) one there.”

Google reviews were worse: “They might have killed nana,” said one from eight months ago.

Another, from 11 months ago, looked to be from a resident: “Everything is terrible. Here.”

“I live here,” said another, a year old. “Staff sucks food sucks everything sucks.”

On a Tuesday afternoon in early May, ProPublica spoke with a group of residents outside the plywood-roofed vestibule that serves as an entrance of the home. Some of the residents were clearly impaired, capable of only grunts and mumblings. Others were quite coherent, and they rattled off an array of dark observations and complaints.

“Lots of people die here,” said one man.

“All they feed us is chicken,” said another. “Chicken, chicken, chicken. Never beef.”

They spoke of fights and of thievery. Of hostility from the aides and indifference from state inspectors.

The resident who seemed to have the best command of conditions at the home was Vargas, the unofficial mayor who said he had been recruited to Oceanview after he’d ended up in a nursing home. For his first six months at the home, he said, he never left his room.

“I hated everyone here,” he said. “I told the guy that brought me here, ‘If I see you in the street, I’m going to kick your ass.’”

But in time his hatred gave way to a kind of begrudging compassion. He felt sympathy toward his fellow residents. He said in time he began pushing both the management and the government to improve conditions at the home. He had been at Oceanview about a year when he became president of the home’s residential council — an internal group formed with the help of the nonprofit Coalition of Institutionalized Aged and Disabled.

Vargas said he had been to the statehouse in Albany with the organization and had repeatedly called the Department of Health to make complaints about the home concerning everything from the food to the way the home matches roommates with one another. He’d caught one of his roommates chopping up pills to snort off his bureau.

In November 2015, a toilet above him flooded and began leaking into his room. When he tried to get help, he said the home’s staff ignored him. Frustrated, he tried to find the administrator. When he went to her office, no one answered. So he kicked the door down. She wasn’t there, but it was captured on a surveillance tape and she sought to evict him.

Today, Vider, the administrator, has an order of protection against Vargas. Vargas and his lawyer said the administrator is retaliating against him for his advocacy.

As Vargas relayed his story, he was constantly interrupted by people nudging him to buy cigarettes.

“It’s how I can afford to eat out,” he said.

As he started to say how he sees people from the home regularly eating out of garbage cans, an elderly resident with dirty latex gloves tied to his belt loops rummaged through a nearby trash can. He pulled out a dented can of malt liquor, turned it upside down, and swallowed what was left of it.

Vargas said he gets a good deal on cartons of cigarettes at a nearby store, marks them up and sells them at a small profit to fellow residents. With his earnings, he said he can afford to order tacos and sandwiches from takeout restaurants nearby.

“I charge them nine dollars a pack if they pay upfront. Thirteen if they pay in a week.”

He pulled out a ledger he keeps in a tattered notebook, entering transactions so he can keep track of who owes him what with an inky black pen.             

Vargas’ bestsellers are Cheyenne Cigars. They are a bargain at $3 a pack. A lit, brown Cheyenne seemed to dangle from the mouth of just about every resident that afternoon. Some of those without foraged for them, their heads bowed, scouring the pavement for salvageable butts.

He said his biggest paydays come on the first and third of each month.

Those are the days the residents get their monthly allowance of $195, left over from the monthly state and federal funding that goes to their rent. He said those with last names that fall in the first half of the alphabet get their money on the first, the second half on the third. Those that can’t handle that much money at once get $6 a day.

The first and third, consequently, can turn into big party nights at Oceanview.

“They go out and buy beer and come back and get wasted,” Vargas said. “It gets like a zoo in here.”

That night, a man in a bright orange shirt who spoke in grunts was stabbed by an old man with a walker. Vargas said the old man had been drinking and became infuriated when the much larger, younger man spat in his face after he refused to light his cigarette.

“It wasn’t the first time he has had to defend himself,” Vargas said.

While Vargas said he does not carry a weapon, he said he does carry handcuffs, which he decided to buy not long after he moved in. He lets them dangle from his walker or belt buckle.

“They see them, they think twice,” he said.

When the police came they took the victim to the hospital, obtained the knife and left.

“They’re sick of us,” Vargas said.

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Nine days later, at about 8 p.m. on May 11, two lines formed in opposite directions between the smoking room and several rows of chairs facing a television inside the facility. One line was for juice and cookies; the other was for medication.

As the residents consumed one or the other or both, a man loaded vending machines with potato chips, popcorn and cheese doodles. A woman with open sores from her feet to her knees slouched in a wheelchair, behind the grease-stained door of the vending machine the man held open. Her head was shaved. Her mouth was agape. She was drooling. The man loading the machine ignored her.

That night, Vargas was sitting on his walker in the ground-floor entertainment room. He said he doesn’t actually need the walker, but he prefers to sit on it because he is certain all the seats in the room have been soiled by incontinent residents. He insists that any guest of his sit on a plastic bag.

A woman with white hair played dominoes and occasionally joined the conversation.

“Well, I’m a nasty bad ass bitch, that’s what I am,” she said, laughing. “Here, you learn to be different than you were on the outside.”

Thirty minutes later, a line of police officers, emergency medical responders and firemen filed into the home.

The woman with the white hair cried out and pointed at them. “This is a frequent occurrence!”

The woman with the open sores moaned loudly. No one checked on her.

“Shut the fuck up!” someone screamed.

The emergency responders were there to attend to a man who had died. When a reporter followed them up to the fourth floor, he was told by police to leave. But one officer walked down the hallway and hurriedly whispered the addresses of two other adult homes in the area.

“I’m glad you’re interested in this,” the officer said.

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Talk to neighborhood beat officers about Oceanview Manor and they respond with the same knowing nod. One officer, standing in front of Big Sam’s bodega on a nearby corner, said, “Their families throw them in there. You know, they don’t have much money. Then they walk around here like zombies, begging for change. I think the people in the neighborhood are pretty used to it. No one complains much.”

The police, who did not want their names used because they were not authorized to speak publicly on the matter, readily acknowledged there wasn’t a whole lot they could do for troubled residents. Instead, they find themselves on a kind of carousel: Residents go off their medication. They have a psychotic episode. Police are called in. Police bring them to a nearby psychiatric ward, usually at Coney Island Hospital. Then the residents go back. Sometimes in hours, sometimes days. But they always seem to go back.

“It is what it is,” another officer said, shrugging his shoulders as he sat in his patrol car in front of Oceanview on a recent Sunday morning. “Beats driving around aimlessly.”

John Doe, in seeking to return to Oceanview, listed the appeal of the neighborhood, its conveniences and safety.

On Friday, May 12, however, one night after the death at Oceanview, two patrol officers responded to a confrontation blocks from Oceanview. A man was eventually put on the ground and searched, and a small handgun was recovered.

One of the officers, holding the gun up, and maybe thinking a reporter was a tourist, said, “This is what you get when you come to Coney Island.”

The Fire Department’s records reflect an enormous volume of runs to Oceanview. In January, the department responded to medical calls four days in a row.

In June of last year, the Fire Department was called in to address something referred to in the records as a “Brush Fire.” A week later, on July 1, the Fire Department was called in on the rare all-hands alarm. Fire alarms went off at least three more times in the next month.

Sherrin, the lawyer for Oceanview, said the issue of what he termed false alarms at the home were common “in every setting with a mental health population.”

He acknowledged the problem of police shuttling residents to and from local psychiatric facilities was real, but he said blame rested with a “system that doesn't allow the hospitals to keep people longer for observation or treatment.”

Sherrin said the homes are required by law to send residents to the hospital when there is a concern over their physical or mental health. He said that when the homes object to taking possibly dangerous residents back prematurely, advocates for the disabled sue the homes for denying their clients re-entry.

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On Mother’s Day, a slight, 82-year-old woman in a pink sweater named Dionne Ward emerged from the front door of Oceanview. She was worried.

“Every time I see an empty seat, I start worrying,” she said.

She was referring to her only friend at the home, 57-year-old Diane Jenkins, who had not taken her seat in the dining room at breakfast. The two of them usually faced each other in the cafeteria, their elbows resting on the floral-patterned plastic table cloths as they talked. 

Oceanview is supposed to provide an assortment of services for the residents. The residents said a psychiatrist visits once a week, a psychologist three times; aides are responsible for as many as eight residents at any given time; a calendar lists dates for dominoes and movies.

In the days ProPublica spent at Oceanview, however, there was little evidence of supervision or organized activities. Some residents spoke of trips to the boardwalk or the amusement park, but described not much else in the way of care or companionship.

And so when Ward and Jenkins talked, they complained of the food, of boredom, of other residents. Jenkins was sure her roommates were stealing from her; Ward was sure the home had gotten her medication wrong. That she had been “drugged.”

In 2002, The New York Times examined a decade’s worth of deaths at adult homes. At 26 of the largest and most troubled homes in the city, the Times documented 946 deaths from 1995 through 2001. Of those, 326 were of people under 60, including 126 in their 20s, 30s and 40s. As the Times noted, some of the hundreds of deaths obviously resulted from natural causes and were unavoidable. Studies have found the mentally ill typically have shorter life expectancies than the general population, because they have difficulty caring for themselves and are more prone to health problems. Still, the Times analysis showed that some residents died roasting in their rooms during heat waves while others threw themselves from rooftops. Sometimes, residents, lacking the most basic care, perished from treatable ailments.

With Jenkins missing from breakfast on Mother’s Day, concern felt natural. It had only been about 72 hours since the man in Room 406 had died. His memory was now preserved by a photograph, his gap-toothed smile framed by a graying mustache, tacked to a wall behind the front desk.

Ward saw a police squad car was parked out front of the home. Vargas soon came out and said that police were on the third floor investigating a death. They were in Jenkins’ room.

Ward sighed.

“Oh. Oh no,” she said. “Now who will I talk to?”

Sherrin, the lawyer for Oceanview, said all deaths at the home are properly reported to the authorities, and that if there was any cause for concern, they would as a result be investigated. Sherrin did not respond to ProPublica’s request to see the home’s records of death reports to the authorities.

Ward, still pained by Jenkins’s passing, remembered their last conversation. A day or two prior, Jenkins had told her, sort of out of nowhere, “I don’t belong here.”

Ward remembered nodding in agreement.

“I know the feeling,” she said.

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In 2013, New York state announced an initiative to establish 4,500 assisted living beds within its already troubled adult homes. Oceanview was one of 18 New York City adult homes approved to participate. It started off with 116 in 2014, and Department of Health records now indicate it has 160 beds available to residents as part of the assisted living program.

Homes with an assisted living component are supposed to provide services ranging from the very basic, like room and board and common space, to the more advanced, like individualized plans of assistance, case management, and home health services.

“The philosophy of assisted living emphasizes personal dignity, autonomy, independence, privacy, and freedom of choice,” according to Department of Health documents. It was designed as an alternative to nursing homes that offer occupants less independence.

But advocates charge that the assisted living program is not much more than a financial boon for the adult home industry with few tangible benefits for residents.

“It presents an opportunity for the homes to make even greater profits,” said Jota Borgmann, a senior attorney for MFY Legal Services, which represents residents in a variety of litigation involving adult homes. She said the program affords maximum discretion to home administrators in determining a resident’s level of need. Under current rules, administrators can charge Medicaid as much as $128.69 extra per resident, per day.

A report done several years ago by the nonprofit Long Term Care Community Coalition laid out the risks:

“Because ALP providers were never required to meet standards beyond those of the traditional licensed adult homes (many of which provide scandalously poor conditions for their residents), consumers are at the mercy of individual providers as to whether or not their facility will provide (or not provide) the home-like environment, quality of life and choices that we consider to be the hallmarks of assisted living.”

Some advocates fear that adult homes are getting around the regulations governing their populations by simply categorizing mentally ill residents as assisted living residents, shifts the residents may not have the capacity to understand or approve.

In interviews, four residents who said they did not suffer from mental illness said they were brought to the home through some version of the assisted living program.

Vargas complained that he and others have aides pushed on them. Other residents told ProPublica that if they didn’t accept the help of an aide, they’d be thrown out of the home. All four said they were not informed prior to their arrival that they were entering homes that served the mentally ill.

“Nobody told me this place was mental,” Vargas said. “The first day I got here I was freaked out. I was like, what is this, ‘The Walking Dead’?”