North Shore - LIJ Orzac Center For Rehabilitation

Based on observations, record review, and interviews conducted during a Recertification Survey initiated on 5/12/2025 and completed on 5/16/2025, the facility did not ensure that food was stored and prepared in accordance with professional standards for food service safety. This was identified during the Kitchen observation conducted on 5/12/2025. Specifically, the walk-in refrigerator for meat had uncooked pork bacon and prepared raw steak stored over raw salmon. In addition, eight trays of assorted pre-cupped salad dressings were observed in the reach-in refrigerator and were not discarded after the must use-by date. The finding is: The facility's policy titled, Receiving and Storage last revised March 2023 documented that all food and supplies must be properly received and stored to prevent contamination and spoilage of foods in storage. Raw animal foods in refrigerated storage are stored away from cooked meats, fruits, vegetables, and ready-to-eat foods. The policy did not document proper storage of raw meats, poultry, and seafood in refrigerators when separation was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the Recertification Survey initiated on 5/12/2025 and completed on 5/16/2025 the facility did not ensure that each resident received care, consistent with professional standards of practice, to prevent pressure ulcers. This was identified for one (Resident # 6) of the three residents reviewed for Pressure Ulcers. Specifically, Resident #6 had a Stage 4 (full-thickness skin and tissue loss, exposing muscle, tendons, or bone) pressure ulcer to the sacrum. The resident utilized an air mattress for pressure redistribution and prevention of further pressure ulcer development. The air mattress weight setting was not consistent with the resident's actual weight. The findings are: The facility's policy titled Pressure Ulcer Prevention: Guidelines for Nursing Interventions, dated July 2023, documented that Registered Nurse and Licensed Practical Nurse responsibilities included to ensure that all interventions/nurse instructions are being performed appropriately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the Recertification Survey initiated on 5/12/2025 and completed on 5/16/2025, the facility did not ensure it maintained an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #210) of three residents reviewed for the Infection Control Task. Specifically, Resident #210 was admitted to the facility with a Peripherally Inserted Central Catheter in their left arm. The resident was not placed on Enhanced Barrier Precautions. The finding is: The facility's policy titled Enhanced Barrier Precautions, last revised 4/17/2024 documented that Enhanced Barrier Precautions are indicated for indwelling medical devices (including but not limited to central lines, urinary catheters/urostomies, feeding tubes, tracheostomy, drains of any kind, etc.) regardless of Multi-Drug-Resistant Organism status. As per facility practice, a physician's order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record reviews, during an abbreviated survey (NY00338693), the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and comprehensive care plans for 1 (Resident #1) of 3 sampled residents. Specifically, Resident #1 received daily, lower-than-prescribed doses of two medications (Furosemide and Metoprolol) used in the treatment of Congestive Heart Failure for 12 consecutive days. Subsequently, Resident #1 experienced significant weight gain and edema (fluid retention). The facility failed to notify Resident #1's physicians of a change in the resident's condition. Resident #1 was transported to the emergency room and admitted to the hospital and expired 3 days later. Findings include: Facility's Congestive Heart Failure protocol titled Overview of Heart Failure (undated) documented the Signs and Symptoms of Heart Failure which included, but was not limited to, the following: weight gain of 1.5 or more…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the Recertification Survey initiated on 1/25/2024 and completed on 1/31/2024, the facility did not ensure that all allegations of misappropriation were reported to the Administrator of the facility and to other officials within 24 hours of the incident. This was identified for one (Resident #84) of one resident reviewed for Personal Property. Specifically, Resident #84 alleged that Certified Nurse Aide #2 stole 48 dollars in cash on 1/5/2024 and the Administrator was not informed until 1/8/2024. Additionally, the Administrator did not report the allegation to the New York State Department of Health and local law enforcement. The finding is: The facility policy entitled Abuse, Neglect, Exploitation Mistreatment, and Misappropriation of Resident Property dated 2/1989 and revised 11/2022 documented any alleged violation involving misappropriation of resident property shall be reported immediately to the Executive Director/designee, and when required to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the Recertification survey initiated on 1/25/2024 and completed on 1/31/2024, the facility did not ensure that all investigations for misappropriation were completed within 5 working days of the alleged incident. This was identified for one (Resident #84) of one resident reviewed for Personal Property. Specifically, Resident #84 alleged that Certified Nurse Aide #2 stole 48 dollars in cash on 1/5/2024 and the investigation was not completed until 1/24/2024. The finding is: The facility policy entitled Abuse, Neglect, Exploitation Mistreatment, and Misappropriation of Resident Property dated 2/1989 and revised 11/2022 documented Misappropriation of Resident Property is the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. Any alleged violation involving misappropriation of resident property shall be reported immediately to the Executive Director/designee, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (NY 00331732) initiated on 1/25/2024 and completed on 1/31/2024 the facility did not ensure that each resident received treatment and services that meet professional standards of Quality. This was identified for one (Resident #88) of three residents reviewed for Discharge. Specifically, the facility staff did not assess or obtain a Physician's order to perform wound care to Resident #88's spinal surgical wound and administered wound care without a Physician's order. The finding is: The facility's policy titled Dressing and Wound Care, last reviewed September 2023, documented that wound care is performed as per the direction of the Physician/Nurse Practitioner. Review physician orders regarding cleansing agents, treatment orders, and covering dressings. Verify orders on the electronic treatment administration record. Resident #88 was admitted with diagnoses including Parkinson's Disease, Hypertension, and Diabetes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during the Recertification Survey initiated on 1/25/2024 and completed on 1/31/2024, the facility did not ensure that a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or attain the highest practicable mental and psychosocial well-being. This was identified for one (Resident #58) of one resident reviewed for Mood and Behavior. Specifically, Resident #58, who was identified by the facility on 9/22/2023 as having thoughts that they would be better off dead and had a Physician's order for Psychology services added to their chart at their request on 9/22/2023 and renewed in October, November, and December 2023. The resident was never evaluated by the Psychologist. The resident was again identified by the facility on 1/12/2024 as stating they were currently depressed and felt that they…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the Recertification Survey initiated on 1/25/2024 and completed on 1/31/2024, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #243) of one resident reviewed for Skin Condition. Specifically, during the wound care observation of Resident #243's left knee surgical wound, Registered Nurse #3, the treatment nurse, was observed wearing gloves and sanitizing the bedside table, setting up the wound care supplies, and removing the old dressing from the left knee. Registered Nurse #3 then prepared to apply the new dressing. During the entire observation, Registered Nurse #3 did not change their gloves and did not wash their hands. The finding is: The facility's policy titled, Dressing and Wound Care last reviewed September 2023, documented the purpose is to prevent infection of wounds and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the Recertification Survey completed on 1/31/2022, the facility did not ensure that care was implemented to meet each resident's medical and nursing needs for one (Resident #8) of two residents reviewed for Skin Conditions. Specifically, during observation of Resident #8's colostomy care, Registered Nurse (RN) #1 did not apply skin barrier (product used to protect skin from contacting the fecal matter) prior to applying the colostomy wafer (a plastic ring that is applied to the skin around the colostomy and which the colostomy pouch is attached to) as per the Physician's order. The finding is: The facility's policy titled Colostomy Care, last revised 12/2020, documented to apply skin barrier to the peristomal skin (skin around the colostomy opening). Let it air dry. The skin barrier protects the skin from contact with fecal material. Resident #8 was admitted with diagnoses including Cancer, Non-Alzheimer's Dementia, and Colostomy. The Quarterly Minimum…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.