Inspection Reports for
Lawrence Nursing Care Center, Inc
350 Beach 54th Street, Arverne, NY, 11692
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Inspection Report — Jan 22, 2025
Certification/complaint State
Date: Jan 22, 2025
Visit Reason
State-compiled facility profile showing 11 inspections from 2022 to 2025 with deficiency and enforcement history.
Complaint Details
The state logged 81 complaints about this facility; 9 led to on-site inspections. Complaint-related citations numbered 6.
Findings
Across 11 inspections, 8 resulted in citations totaling 45 deficiencies, mostly related to standard health and life safety code issues. The facility had 81 complaints with 9 on-site inspections and 5 enforcement actions with fines totaling $287,177.
Citations (33)
Standard Health Citation — quality of care: Activities did not meet interests or needs of each resident.
Standard Health Citation — quality of care: Administration deficiencies noted.
Standard Health Citation — quality of care: Communication training was inadequate.
Standard Health Citation — quality of care: Garbage and refuse were not disposed of properly.
Standard Health Citation — quality of care: Food procurement, storage, preparation, and serving were not sanitary.
Standard Health Citation — quality of care: Infection prevention and control deficiencies found.
Standard Health Citation — quality of care: Nurse staffing information was not properly posted.
Standard Health Citation — quality of care: Protection and management of personal funds was deficient.
Standard Health Citation — quality of care: QAPI training was inadequate.
Standard Health Citation — quality of care: Requirements before submitting a request were not met.
Standard Health Citation — quality of care: Respiratory/tracheostomy care and suctioning were deficient.
Standard Health Citation — quality of care: Environment was not safe, clean, comfortable, or homelike.
Standard Health Citation — quality of care: Environment was not safe, functional, sanitary, or comfortable.
Standard Health Citation — quality of care: Subsistence needs for staff and patients were not met.
Standard Health Citation — quality of care: Nursing staff were insufficient.
Standard Health Citation — quality of care: Surety bond-security of personal funds was deficient.
Life Safety Code Citation — NFPA requirements: Building construction type and height did not meet standards.
Life Safety Code Citation — NFPA requirements: Exit signage was inadequate.
Life Safety Code Citation — NFPA requirements: Hazardous areas were not properly enclosed.
Life Safety Code Citation — NFPA requirements: Maintenance, inspection, and testing of doors were deficient.
Life Safety Code Citation — NFPA requirements: Physical environment deficiencies noted.
Life Safety Code Citation — NFPA requirements: Vertical openings were not properly enclosed.
Standard Health Citation — quality of care: Free of accident hazards, supervision, and devices was deficient.
Standard Health Citation — quality of care: Reporting to National Health Safety Network was deficient.
Standard Health Citation — quality of care: Accuracy of assessments was deficient.
Standard Health Citation — quality of care: Care plan timing and revision were deficient.
Standard Health Citation — quality of care: Quality of care deficiencies noted.
Standard Health Citation — quality of care: RN coverage 8 hours/7 days/week was deficient.
Standard Health Citation — quality of care: Treatment/service for dementia was deficient.
Life Safety Code Citation — NFPA requirements: Cooking facilities were deficient.
Life Safety Code Citation — NFPA requirements: Emergency lighting was deficient.
Standard Health Citation — quality of care: Free from abuse and neglect was deficient.
Standard Health Citation — quality of care: Reporting of alleged violations was deficient.
Report Facts
Inspections on page: 11
Total violations/deficiencies cited: 45
Inspections with violations: 8
Inspections without violations: 3
Total complaints: 81
On-site complaint inspections: 9
Citations from complaints: 6
Enforcement actions: 5
Total fines: 287177
Inspection Report — Jan 22, 2025
Recertification CMS
Date: Jan 22, 2025
Visit Reason
Recertification survey conducted from 01/14/2025 to 01/22/2025 to assess compliance with regulatory requirements and investigate complaint #NY00363144.
Complaint Details
Complaint #NY00363144 triggered the survey due to concerns about low staffing on weekends and nights, resulting in delayed care and increased risk of resident falls.
Findings
The facility was found deficient in multiple areas including failure to maintain residents' personal funds in interest-bearing accounts, insufficient surety bond coverage, poor environmental cleanliness and maintenance, inadequate activities programming, improper respiratory care, insufficient nursing staff especially on weekends, incomplete nurse staffing postings, unsafe food handling practices, improper garbage disposal, ineffective administration, inadequate infection control practices, unsafe and unsanitary facility environment, and lack of mandatory staff training on effective communication and quality assurance programs.
Citations (14)
F0567: Facility did not ensure residents' personal funds were placed in interest-bearing accounts as required, affecting 2 residents.
F0570: Facility surety bond did not cover the total amount of resident personal funds deposited, affecting 185 resident accounts.
F0584: Facility failed to maintain a safe, clean, comfortable, and homelike environment; multiple units had soiled rooms, broken plaster, stained window treatments, and soiled wheelchairs.
F0679: Facility did not provide an ongoing activities program meeting residents' interests and needs; Resident #42 was observed without meaningful activities.
F0695: Facility did not provide safe and appropriate respiratory care; Resident #138 did not receive continuous oxygen as per physician orders.
F0725: Facility did not provide sufficient nursing staff daily to meet residents' needs; staffing was consistently below projected levels, especially on weekends.
F0732: Facility did not post daily nurse staffing information including actual hours worked by licensed and unlicensed nursing staff.
F0812: Facility did not store, prepare, distribute, and serve food in accordance with professional standards; undated food, improper freezer temperatures, standing water in dry storage, and staff not wearing hair restraints were observed.
F0814: Facility did not properly dispose of garbage; compactor door left open, garbage overflowing, and litter observed around dumpster.
F0835: Facility administration failed to ensure effective and efficient use of resources; repeated deficiencies and environmental concerns persisted without adequate corrective action.
F0880: Facility failed to implement infection prevention and control program; Enhanced Barrier Precautions and proper hand hygiene were not maintained during tube feeding for Resident #169.
F0921: Facility did not maintain a safe, clean, and comfortable environment; multiple areas including front entrance, elevators, staff bathrooms, and nursing stations were dirty, damaged, or in disrepair.
F0941: Facility did not provide effective training on communication for direct care staff; 6 reviewed CNA training files lacked mandatory effective communication training.
F0944: Facility did not provide mandatory training on Quality Assurance Performance Improvement program to staff; 6 reviewed CNA training files lacked this training.
Report Facts
Resident accounts affected: 185
Resident sample size: 39
Staffing schedules reviewed: 92
Garbage bags observed: 14
Freezer temperature: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding oxygen therapy rate error for Resident #138 |
| Director of Nursing | Director of Nursing | Interviewed about staff training and oxygen therapy expectations |
| Administrator | Administrator | Interviewed about staffing challenges, facility maintenance, and quality assurance |
| Director of Maintenance | Director of Maintenance | Interviewed about facility maintenance and housekeeping challenges |
| Director of Nutrition | Director of Nutrition | Interviewed about food safety and garbage disposal issues |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed about infection control practices |
| Certified Nursing Assistant #6 | Certified Nursing Assistant | Interviewed about staffing shortages and workload |
| Certified Nursing Assistant #8 | Certified Nursing Assistant | Interviewed about staffing shortages and workload |
Inspection Report — Jan 22, 2025
Complaint Investigation CMS
Date: Jan 22, 2025
Visit Reason
The inspection was conducted as a Recertification and Abbreviated Survey triggered by Complaint #NY00363144 regarding staffing shortages and resident care concerns.
Complaint Details
Complaint #NY00363144 alleged staffing cuts on weekends and overnight shifts resulting in only one Certified Nursing Assistant for approximately forty residents per floor, creating unsafe conditions and delayed care. The complaint was substantiated by interviews and staffing data.
Findings
The facility was found to have consistently insufficient nursing staff, especially Certified Nursing Assistants on weekends and nights, resulting in delayed resident care and increased risk of harm. Staffing schedules and Payroll Based Journal data confirmed low staffing levels, and multiple resident and staff interviews corroborated these findings.
Citations (1)
F 0725: The facility failed to provide enough nursing staff every day to meet the needs of every resident and have a licensed nurse in charge on each shift. Staffing assignments were consistently less than projected needs, especially Certified Nursing Assistants on weekends and nights, causing delays in care and increased risk of resident falls.
Report Facts
Required licensed nurses: 30
Required Certified Nursing Assistants: 50
Certified Nursing Assistants scheduled vs worked: 4
Certified Nursing Assistants actually worked: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #6 | Reported staffing shortages and difficulty answering call bells | |
| Certified Nursing Assistant #8 | Reported delays in resident care due to low staffing | |
| Licensed Practical Nurse #2 | Reported frequent understaffing and assisting Certified Nursing Assistants | |
| Registered Nurse #3 | Reported no resident complaints but acknowledged understaffing and agency staff callouts | |
| Human Resources Director | Discussed staffing challenges, Payroll Based Journal data, and agency staffing | |
| Administrator | Discussed staffing based on census, agency contracts, and incentives offered |
Inspection Report — Feb 5, 2024
Abbreviated Survey CMS
Date: Feb 5, 2024
Visit Reason
The abbreviated survey was conducted to assess the facility's compliance with safety and supervision regulations, specifically related to resident supervision and accident hazard prevention.
Findings
The facility failed to ensure adequate supervision of Resident #1, who eloped from the building unnoticed for over four hours. Staff failed to properly monitor and document the resident's whereabouts, and security allowed the resident to exit without proper identification or sign-out procedures.
Citations (3)
F 0689: The facility did not ensure Resident #1 received adequate supervision, resulting in the resident leaving the building for over four hours without staff awareness. Staff failed to properly monitor and document the resident's location during scheduled visual checks.
Security failed to verify Resident #1's identity or require sign-out before allowing exit, contrary to facility policy. The Social Worker at the front desk did not observe the resident exiting, and the Security Guard buzzed the resident out without proper verification.
Medication administration documentation was inaccurate; Resident #1 was given medication at 5:30 PM but documented at 8:24 PM. Licensed Practical Nurse failed to notify the physician about the need to change medication schedule.
Report Facts
Residents sampled: 7
Medication dosage: 20
Medication administration time discrepancy: 174
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Documented progress notes and conducted investigation |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Assigned to Resident #1 and responsible for visual checks; failed to properly monitor and document |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Assigned to Resident #1 during 3 PM - 11 PM shift; last saw Resident #1 at dinner and participated in search |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Not assigned to Resident #1 but responsible for visual checks; did not sign monitoring sheet |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Administered medication late and failed to notify physician about schedule change |
| Security Guard #1 | Security Guard | Buzzed Resident #1 out without verifying identity or sign-out |
| Director of Nursing | Director of Nursing | Notified of missing resident, reviewed video footage, and investigated incident |
| Administrator | Administrator | Notified of incident and stated facility lacked visual monitoring policy |
Inspection Report — Jan 5, 2023
Recertification CMS
Date: Jan 5, 2023
Visit Reason
The inspection was a Recertification survey conducted from 12/22/22 to 01/05/23 to assess compliance with federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including inaccurate Minimum Data Set assessments, incomplete and outdated comprehensive care plans, failure to provide wound care treatments as ordered, inadequate respiratory care including tracheostomy care, insufficient nursing staff to meet resident needs, the Director of Nursing serving as charge nurse due to staffing shortages, inadequate dementia care planning, and lapses in infection control practices.
Citations (8)
F0641: The facility did not ensure Minimum Data Set 3.0 assessments accurately reflected a resident's status, specifically Resident #16's PASRR coding was incorrect.
F0657: The facility did not ensure resident Comprehensive Care Plans were reviewed and revised with each assessment and as needed, affecting Residents #98 and #62.
F0684: Resident #120 did not receive wound care treatments according to Medical Doctor orders, with multiple documented missed treatments.
F0695: Licensed Practical Nurse #7 provided tracheostomy care to Resident #168 without changing Velcro straps, suctioning, or performing hand hygiene as ordered.
F0725: The facility did not ensure sufficient nursing staff to meet resident needs, with documented staffing shortages and residents reporting lack of nurses on units.
F0727: The Director of Nursing served as charge nurse and administered medications when the facility was short staffed, contrary to policy for facilities with occupancy over 60 residents.
F0744: Resident #145 with dementia did not have a person-centered comprehensive care plan that was reviewed or revised to address cognitive loss and wandering behaviors.
F0880: Infection control breaches occurred during tracheostomy care for Resident #168, including placing items on the bed and failure to perform hand hygiene.
Report Facts
Residents sampled: 39
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 3
Staffing requirement: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Licensed Practical Nurse | Named in tracheostomy care and infection control deficiencies for Resident #168 |
| LPN #2 | Licensed Practical Nurse | Named in wound care deficiency for Resident #120 |
| Director of Nursing | Director of Nursing | Named in staffing and charge nurse role deficiencies |
| Administrator | Administrator | Interviewed regarding staffing shortages and facility efforts |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Reported staffing shortages on unit |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Reported behaviors of Resident #145 and lack of dementia inservice |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Reported behaviors of Resident #145 and lack of dementia inservice |
| Assistant Director of Nursing | Assistant Director of Nursing/Infection Preventionist | Interviewed regarding infection control and training |
| Director of Social Services | Director of Social Services | Interviewed regarding care plan review responsibilities |
Inspection Report — Dec 3, 2019
Annual Inspection CMS
Date: Dec 3, 2019
Visit Reason
The inspection was a Recertification Survey to assess compliance with regulatory requirements for Lawrence Nursing Care Center, Inc.
Findings
The facility was found deficient in ensuring residents were free from physical restraints without proper medical justification and assessments. Additionally, care plans were not fully implemented for rehabilitation and dialysis monitoring as ordered.
Citations (2)
F 0604: The facility did not ensure residents were free from physical restraints without proper evaluation and physician orders. Resident #157 was placed in a reclining Geri-chair without assessment or order, and Resident #7 used two half side rails without evaluation or care plans.
F 0656: The facility failed to implement care plans as ordered. Resident #6's floor ambulation program was not performed due to unavailability of a quad cane, and Resident #143's dialysis AV shunt was not monitored for bruit and thrill every shift as ordered.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| OT #1 | Occupational Therapist | Interviewed regarding lack of assessment for Resident #157's use of Geri-chair |
| Director of Rehabilitation | Interviewed about assessments and referrals related to Resident #157 and Resident #7 | |
| Director of Nursing Services | Interviewed about issuance of Geri-chair and care plan updates | |
| Administrator | Interviewed about restraint assessments and care plan compliance | |
| CNA #1 | Certified Nursing Assistant | Interviewed about Resident #157's use of Geri-chair |
| LPN Charge Nurse | Licensed Practical Nurse | Interviewed about orders and knowledge of Geri-chair issuance for Resident #157 |
| RN Supervisor | Registered Nurse Supervisor | Interviewed about side rail assessments for Resident #7 |
| Licensed Practical Nurse | Interviewed about monitoring bruit and thrill for Resident #143 |
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