West Lawrence Care Center. LLC

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification and Complaint Survey from 07/28/2025 to 08/04/2025, the facility did not ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was evident during review of Staffing, Residents' food preferences, Dignity, Home like Environment, Resident Assessment, and Abuse, 1.) The Administration did not ensure the facility was sufficiently staffed to meet the residents' needs, residents' assessments were accurate, and their dietary preferences met. [...]

Inspectors wroteBased on interview, observation and record the facility did not ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. Specifically, the facility policy and practices did not honor resident's food preferences and required all residents to consume Kosher meals. In addition, residents were permitted to consume outside food or meals prepared or brought in by family members unless prior arrangements were made with facility staff. When outside food was permitted, residents were not allowed to consume these foods in an area of the facility of their own choosing as this food could only be consumed in the Recreation area. Residents were only permitted to purchase outside food once weekly with their own funds. [...]

Inspectors wroteBased on interview and review of the facility Daily Staffing Reports and Payroll Based Journal Staffing Data Report of Quarter 2 2025 (January 1 to March 31) which indicated Excessively Low Weekend Staffing and One Star Staffing Rating, it was determined that the facility did not ensure there was sufficient nursing staff on a 24-hour basis to provide nursing care to the residents.

Inspectors wroteBased on observation, record review and interviews conducted during a Recertification survey, the facility did not ensure that they had a policy regarding the use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Specifically, the facility policy did not ensure that facility staff were able to assist residents in accessing and consuming food brought from outside, and did not permit storage of food brought in by family or visitors. Based on observation, record review and interviews conducted during a Recertification survey, the facility did not ensure that they had a policy regarding the use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. [...]

Inspectors wroteNumber of residents sampled: 3Number of residents cited: 1Based on observations, record review, and interviews conducted during the Recertification Survey the facility did not ensure that the residents were treated with respect and dignity and cared for in a manner and in an environment that promotes maintenance or enhancement of resident quality of life. This was evident for 1 (Resident #90) of 3 residents reviewed for Activities of Daily Living out of an investigative sample of 34 residents. Specifically, Resident #90 with a history of refusing care was observed on multiple occasions having a strong urine odor on their person while in common areas and in their room shared with other residents.

Inspectors wroteNumber of residents sampled:2Number of residents cited:1 Based on record review and interview conducted during the Recertification survey, the facility did not ensure that, to the extent practicable, the resident participated in the development, review, and revision of the comprehensive care plan. This was evident for 1 (Resident #34) of 2 residents reviewed for Care Planning, out of 34 sampled residents. Specifically, Resident #34's care plan meeting had not been scheduled nor held since their admission on [DATE].

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 07/28/2025 to 08/04/2025, the facility did not ensure a resident's right to receive services with reasonable accommodation of their needs and preferences. This was evident for 1 (Resident #151) of 31 total sampled residents. Specifically, Resident #31 was observed in their and they were not able to wash their hands in their bathroom sink without leaning forward and risk falling out of their wheelchair, their bathroom mirror was not on positioned appropriately for grooming, the cabinet in their room was at a height to allow them to access items in the cabinet, and the bottom drawers in their cabinet were difficult to access making it difficult for Resident #151 to access their clothing.

Inspectors wroteNumber of residents sampled:3Number of residents cited:1Based on interviews and record review conducted during the Recertification survey, the facility did not ensure a resident, or their designated representative was provided appropriate notification at the termination of Medicare Part A benefits. This was evident for 1 (Resident #27) of 3 residents reviewed for Beneficiary Notification out of 34 total sampled residents. Specifically, the Notice of Medicare Non-Coverage was not mailed out to Resident #27's designated representative on the same day telephone notification was made.

Inspectors wroteNumber of residents sampled: 6Number of residents cited: 1Based on record review and staff interviews conducted during a Recertification and Complaint (759838) survey, the facility did not ensure that each resident is free from abuse, neglect, and corporal punishment of any type by anyone. This was evident for 1 (Resident #13) out 6 residents reviewed for Abuse. Specifically, Resident #13 was bit on their right arm by Certified Nursing Assistant #2 while being assisted with Activities of Daily Living on 03/23/2025.

Inspectors wroteNumber of residents sampled: 4Number of residents cited: 2 Based on record review and interview conducted during the Recertification and Complaint Survey (759831), the facility did not ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegations were made, to the State Survey Agency. This was evident for 2 (Resident #51 & Resident #104) of 4 resident reviewed for Abuse out of 34 total sampled residents. Specifically, the facility's incident report documented that on 11/11/2024 at 10:00 AM, Resident #51 hit Resident #104 with the leg rest of Resident #51's wheelchair, accusing them of stealing underwear. The Administrator was first made aware of the incident on 11/11/2024 at 10:45 AM, and the facility did not report the abuse allegation to the New York State Department of Health until 11/11/2025 at 02:52 PM.

Inspectors wroteBased on observations, record review, and interviews during the Recertification and Complaint (759832) survey conducted from 7/28/2025 to 8/02/2025, the facility did not ensure that they permitted each resident to remain in the facility, and did not transfer or discharge the resident from the facility unless the transfer or discharge was necessary for the resident's welfare and the resident's needs cannot be met in the facility. This was evident for 1 (Resident #151) out of 5 reviewed for Choices out of a sample of 34 residents. Specifically, Resident #151 was not permitted to return to the facility after they went out on pass and returned late and was instead transferred to the hospital. In addition, the facility failed to provide any documentation regarding Against Medical Advice status or a discharge notice provided to the resident prior to hospital transfer.

Inspectors wroteNumber of residents sampled: 3Number of residents cited: 1 Based on record review and interviews conducted during the Recertification survey from 07/28/2025 to 08/04/2025, the facility did not ensure Comprehensive Care Plans were reviewed based on changing goals, preferences and needs of the resident and in response to current interventions. This was evident for 1 (Resident #90) out of 3 residents investigated for Activities of Daily Living out of a total investigative sample of 34 residents. Specifically, Resident #90 was observed on multiple occasions with strong odor of urine on their person and in their room, and there was no evidence that the Comprehensive Care Plan was revised to include interventions to address Resident #90's ongoing behavior of refusal of care.

Inspectors wroteNumber of residents sampled: 5Number of residents cited: 1Based on observation, record review, and interviews during the Recertification survey, the facility did not ensure that a therapeutic diet was provided when there is a nutritional problem, and the health care provider orders a therapeutic diet. This was evident for 1 (Resident #83) of 5 residents reviewed for Nutrition out of a total of 34 sampled residents. Specifically, Resident #83, who had a Physician's order for pureed food and honey thickened liquid, was observed eating leftover chopped beans and drinking apple juice from the tray of another resident prescribed a chopped diet and thin liquids.

Inspectors wroteBased on observation and interview the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This was observed in the 1st Floor visitor bathroom Specifically, from 07/28/2025, to 07/30/2025 the visitor and staff female bathroom located on 1st floor was observed with large, rusted area on the bottom of the bathroom barrier, a missing tile creating a hole at back of the toilet, the light fixture was uncovered, and there was mis-matched paint on the walls.

Inspectors wroteBased on observations and interviews conducted during the Recertification survey, the facility did not ensure that that the notice of the availability of the most recent New York State Department of Health survey report and plan of correction, was posted in areas that are prominent and readily accessible to the public. Specifically, there were no prominent postings of notices of availability throughout the facility. In addition, members of the Resident Council were unable to identify locations where signs or postings documented the availability and location of the survey results.

Inspectors wroteNumber of residents sampled: 5Number of residents cited: 2Based on record review and interview conducted during the Recertification survey, the facility did not ensure the Minimum Data Set 3.0 assessments accurately reflected resident's status. This was evident for 1 (Resident #89) of 1 resident reviewed for Dental and 1 (Resident #34) of 4 residents reviewed for Accidents out of 34 total sampled residents. Specifically, 1). The Minimum Data Set Assessment did not reflect Resident #89's dental status as edentulous, and 2). The admission Minimum Data Set assessment did not reflect Resident #34 had a fall prior to admission.

Inspectors wroteBased on observation, record review, and interviews during an abbreviated survey, (NY00325381), the facility did not ensure the resident's right to be treated with respect and dignity including the right to be free from physical or chemical restraints imposed for the purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. This was evident for one (1) out of three (3) residents sampled (Resident #1). Specifically, on 10/04/2023, Registered Nurse Supervisor #1 documented received a call from License Practical Nurse #1 at approximately 8:20 AM. License Practical Nurse #1 and Certified Nursing Assistant #1 stated Resident #1's left arm was tied to the siderail of the bed with a sock. Registered Nurse Supervisor #1 interviewed Resident #1 and Resident #1 stated they were tied up all night and was experiencing pain. [...]

Inspectors wroteBased on observation, record review, and interviews during an abbreviated survey (NY00325381), the facility did not ensure that a resident who is unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. This was evident for one (1) out of three (3) residents sampled (Resident #1) Specifically, on 10/03/2023 during the 11:00 PM-7:00 AM shift, Certified Nursing Assistant #3 stated they did not provide personal care to Resident #1 because they forgot and falsely documented care was provided. The surveillance video was reviewed and confirmed that Certified Nursing Assistant #3 did not provide any activity of daily living care to Resident #1. On 10/04/2023 at 8:30 AM, Resident #1 was observed saturated with urine. Certified Nursing Assistant #3 was terminated.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 7/10/2023 to 7/14/2023, the facility did not ensure residents or their representatives were offered the opportunity to participate in the revision and/or review of the comprehensive care plan (CCP) and that the CCP was reviewed and revised upon each assessment. This was evident for 7 (Resident #s 43, 97, 145, 48, 59, 110, and 98) of 31 total sampled residents. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 7/10/2023 to 7/14/2023, the facility did not ensure the attending physician documented in the resident's medical record that an identified irregularity from the pharmacy has been reviewed and what, if any, action has been taken to address it. This was evident for 2 (Resident #74 and #10) of 5 residents reviewed for Unnecessary Medication out of 31 total sampled residents. Specifically, 1) there was no documented evidence the Medical Doctor (MD) responded to pharmacy irregularities for Resident #74, and 2) there was no documented evidence the MD responded to pharmacy irregularities for Resident #10.

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification survey from 7/10/2023 - 7/14/2023, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was observed during the Kitchen Task. Specifically, food items were observed during the initial tour, without proper packaging, labeling, and dating, and 2 dietary staff were observed preparing food without a facial hair covering.

Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification Survey from 07/10/2023 to 0714/2023, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evident for 1 (Unit 4) of 4 units. Specifically, Unit 4 was observed a frayed shower chair with accumulation of black grime at the seams and a recliner shower chair with feces under the seat.

Inspectors wroteBased on record review and staff interview conducted during the Recertification survey from 7/10/2023 to 7/14/2023, the facility did not ensure residents were assessed once every 3 months using the Minimum Data Set 3.0 (MDS) assessment tool. This was evident for 1 (Resident #132) of 31 total sampled residents. Specifically, Resident #132's quarterly MDS assessment was completed more than 92 days after their annual MDS assessment.

Inspectors wroteBased on record review and interviews conducted during the recertification survey from 7/10/2023 to 7/14/2023, the facility did not ensure that the Minimum Data Set 3.0 (MDS) assessments were electronically transmitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in a timely manner. This was evident for 1 (Resident #10) of 31 total sampled residents. Specifically, the MDS assessments for Resident #10 were not submitted and transmitted within 14 days of the completion date.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 07/10/2023 to 0714/2023, the facility did not ensure that the resident and their representative were provided with a written summary of the baseline care plan (BCP). This was evident for 1 (Resident #110) of 31 total sampled residents. Specifically, Resident #110 was not provided with a copy of their BCP within 48 hours of admission to the facility.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 07/10/2023 to 07/14/2023, the facility did not ensure a person-centered comprehensive care plan (CCP) was developed and implemented to address the resident's needs. This was evident for 1 (Resident #110) of 31 total sampled residents. Specifically, a CCP related to Resident #110's use of left palm guard was not developed and implemented.

Inspectors wroteBased on observation, interviews, and record review conducted during Recertification survey from 07/10/2023 to 07/14/2023, the facility did not ensure that a resident received proper treatment to maintain hearing. This was evident for 1 (Resident #127) of 31 total sampled residents. Specifically, Resident #127 did not have a follow up Ear Nose and Throat (ENT) appointment scheduled in accordance with the Audiologist's recommendations.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey of 7/10/2023 to 7/14/2023, the facility did not ensure a resident was prescribed a psychotropic drug to treat a specific condition and received Gradual Dose Reductions (GDR) unless clinically contraindicated. This was evident for 1 (Resident #74) of 5 residents reviewed for Unnecessary Medication of 31 total sampled residents. Specifically, Resident #74 had a diagnosis of dementia and was prescribed an antipsychotic medication to treat depression.

Inspectors wroteBased on record review and staff interview conducted during the Recertification and Abbreviated Survey (NY00268056), the facility did not ensure resident has a right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of another resident. Specifically, the facility did not allow the resident's representatives to visit a resident who was categorized under the exception of end of life status. This was evident for 1of 2 residents reviewed for Choices out of a sample of 38 residents. (Resident # 253)

Inspectors wroteBased on observations, interviews and record reviews during a Recertification and Abbreviated survey, the facility did not ensure that assessments accurately reflected the residents' status. Specifically, the most recent assessment did not reflect that a wander/elopement alarm was used for a resident. This was evident for 1 of 1 residents reviewed for Accidents out of a sample of 38 residents. (Resident # 86) The finding is: Resident #86 was admitted to the facility with diagnoses which include Dementia, Depression, and Psychotic Disorder. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident had moderately impaired cognition and was independent in performing activities of daily living. The MDS further documented in the Section P0200-Alarm that Wander/Elopement Alarm was not used. [...]