ARVERNE, NY — Federal inspectors documented infection control breakdowns, widespread unsanitary conditions, and systemic staff training failures at Lawrence Nursing Care Center during an extended survey completed January 22, 2025. The Arverne facility, located on Beach 54th Street in the Rockaways, was cited across multiple federal regulatory categories after surveyors observed a nurse bypassing required protective protocols while providing feeding tube care to a cognitively impaired resident.
Nurse Bypassed Protective Protocols During Feeding Tube Care
The most clinically significant violation involved a licensed practical nurse who was observed on January 16, 2025, providing enteral feeding care to a resident identified in the report as Resident #169 — a patient diagnosed with non-Alzheimer's dementia, cancer, and malnutrition who relied on a gastrostomy tube for nutrition.
The resident had a physician's order dated January 8, 2025, requiring enhanced barrier precautions due to the presence of wounds, a PEG tube, and a Foley catheter. A sign posted on the resident's door instructed all staff to clean their hands before entering and upon leaving, and to wear both gloves and a gown during high-contact care activities involving feeding tubes, urinary catheters, central lines, or tracheostomies.
Inspectors documented a detailed, minute-by-minute account of what occurred between 4:01 PM and 4:15 PM that day. The nurse entered the resident's room carrying a gown but placed it on the nightstand rather than putting it on. The nurse then washed their hands for approximately 10 seconds — half the minimum time required by the facility's own hand hygiene policy, which mandates 20 to 40 seconds of vigorous rubbing with friction on all surfaces of the hands and fingers.
The nurse applied gloves, cleaned the resident's PEG tube site with water-moistened gauze, flushed the tube, and set the pump. The nurse then left the room to retrieve additional supplies from the medication cart, including gauze pads and normal saline.
Upon re-entering the room, the nurse did not perform hand hygiene and did not put on a gown. The nurse applied fresh gloves over unwashed hands, cleaned the tube site again with normal saline, applied a dry dressing, and connected the feeding. The gown — which had sat unused on the nightstand throughout the entire procedure — was discarded along with the used supplies. The nurse washed hands a second time, again for approximately 10 seconds, before leaving.
Why Enhanced Barrier Precautions Exist
Enhanced barrier precautions were introduced by the Centers for Disease Control and Prevention specifically to combat the spread of multidrug-resistant organisms (MDROs) in long-term care settings. Unlike standard contact precautions, which are triggered by a known infection, enhanced barrier precautions apply to all residents with indwelling medical devices — regardless of whether they are currently colonized with or infected by a resistant organism.
Residents with feeding tubes, urinary catheters, and wounds are at elevated risk because these devices create direct pathways for bacteria to enter the body. A PEG tube site, in particular, bypasses the skin's natural barrier and provides a potential entry point for pathogens directly into the gastrointestinal tract. The combination of wounds, a PEG tube, and a Foley catheter in a single patient — as was the case with Resident #169 — represents a compounding infection risk that makes strict adherence to barrier protocols essential.
Handwashing for 10 seconds rather than the required minimum of 20 seconds significantly reduces the mechanical removal of transient bacteria from the skin. The friction and duration specified in hand hygiene guidelines are not arbitrary — they are based on evidence showing that shorter wash times leave clinically meaningful levels of bacteria on the hands. When a healthcare worker then dons gloves over inadequately washed hands, any remaining bacteria can transfer to gloves and subsequently to the patient's device sites.
The failure to gown compounds this risk. Gowns are required during high-contact care precisely because clothing can serve as a reservoir for organisms, which can then be carried from one patient interaction to the next. The nurse's decision to carry a gown into the room but never wear it suggests awareness of the requirement without actual compliance — a pattern that raises questions about the effectiveness of the facility's training and accountability systems.
What the Nurse Told Inspectors
When interviewed at 4:35 PM — just 20 minutes after the observed care — the nurse acknowledged that handwashing "should last for 20 seconds" but stated they did not believe they had washed for that long. The nurse initially stated the precautions sign on the door indicated "contact precautions" requiring gloves and a mask. After being directed to re-read the sign, the nurse corrected themselves, recognizing it specified enhanced barrier precautions requiring gloves and a gown.
The nurse told inspectors they had received in-service training "some time ago" but could not recall when. The nurse's recollection of the training content was imprecise, stating they remembered being told "to wear gowns for residents who come in from the hospital with some kind of infection" and that enhanced barrier precautions were for residents with "a bacterial infection or something."
This response reveals a fundamental misunderstanding of the purpose of enhanced barrier precautions. These precautions apply regardless of infection status — the entire point is proactive protection for residents with devices that make them vulnerable. Confusing enhanced barrier precautions with infection-triggered isolation protocols suggests the training the nurse received did not effectively convey the distinction.
The facility's Assistant Director of Nursing, who also serves as the Infection Control Preventionist, stated during an interview that staff were informed about hand hygiene and personal protective equipment requirements before starting shifts and during in-service training. The Assistant Director confirmed that handwashing should involve rubbing hands for 20 to 30 seconds.
Widespread Environmental Deficiencies
Beyond infection control, inspectors identified persistent environmental and sanitation problems throughout the facility during the eight-day survey period from January 14 through January 22, 2025. The deficiency was categorized as affecting many residents.
Documented conditions included:
- Cracked and broken pavement at the front entrance walkway - Unstable dining room tables with deteriorating edges exposing inner corking - Both elevators with accumulated dirt and debris in the tracks, streaked and stained doors and walls, and floors embedded with a black substance along the edges - Second-floor staff bathroom with unidentified odors, broken wall tiles, a stained mirror, a dusty paper towel dispenser, embedded dirt along floor edges, and stained walls - Nursing stations on the 2nd, 3rd, and 6th floors with broken and chipped countertops, heavily streaked walls, dust-layered chairs, discolored upholstery, and soiled seating - Dusty hand sanitizer dispensers in the third-floor hallway - Housekeeping equipment — specifically a mop bucket — embedded with black dirt on its exterior
The Director of Maintenance, who was also serving as the Acting Director of Housekeeping Services, told inspectors the facility has "a challenging population" and faces recurring issues with toilet overflows that damage floors, walls, and ceilings. The Director noted the building's age and stated the facility "consistently find[s] themselves patching up problem areas." While acknowledging the issues, the Director said no formulated renovation plan existed, though discussions were underway.
The facility Administrator similarly described the building as old with a difficult population, stating that a renovation proposal for the first-floor lobby and rehabilitation area had been initiated in 2022 but the work had not yet started — more than two years later.
Systemic Staff Training Gaps
Inspectors also identified failures in the facility's mandatory staff training program. A review of orientation records for all six randomly selected Certified Nurse Assistants found that none had received required training in effective communication techniques — a federal requirement for direct care staff in nursing homes.
The same six employee files also lacked documentation of mandatory training on the facility's Quality Assurance and Performance Improvement (QAPI) program. Federal regulations require that all staff understand the goals and elements of a facility's QAPI program, which is designed to identify and address care quality issues on an ongoing basis.
The facility's own staff training policy, dated November 16, 2024, specified that CNAs would receive at least 12 hours of annual education including dementia management, effective communications, and abuse prevention training. However, the policy made no mention of QAPI training, and the Director of Nursing confirmed during an interview on January 22 that neither effective communication training nor QAPI training had been provided. The Director stated they would check whether the Administrator had conducted this training separately but did not provide any follow-up information.
A Pattern of Interconnected Failures
The violations documented at Lawrence Nursing Care Center during this extended survey reflect a pattern in which training deficiencies, environmental neglect, and clinical protocol failures intersect. A nurse who cannot accurately describe the purpose of enhanced barrier precautions raises questions about training quality. Hand sanitizer dispensers covered in dust in hallways where infection control is critical suggest environmental maintenance and infection prevention are not operating in coordination.
The facility is located at 350 Beach 54th Street in Arverne, New York. The full inspection report, including the facility's plan of correction, is available through CMS and the New York State Department of Health. Residents, families, and members of the public can contact the facility or the state survey agency for additional information about the corrective actions being taken.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lawrence Nursing Care Center, Inc from 2025-01-22 including all violations, facility responses, and corrective action plans.
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