North Shore - Lij Orzac Center for Rehabilitation

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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: [...]

Inspectors wroteBased on interviews, observations, and record reviews, during an abbreviated survey (NY00338693), the facility failed to ensure that residents were free from significant medication errors. Specifically, the facility failed to have systems in place to ensure that newly admitted and readmitted residents received their Physician ordered scheduled medications. This was evident for one (Resident #1) of 6 sampled residents. Resident #1 was administered incorrect daily doses of two medications, Furosemide (a diuretic used to reduce fluid retention in patients with certain kidney disorders and chronic heart failure) and Metoprolol (a beta blocker used to treat chest pain, heart failure, and high blood pressure), used in the treatment of Congestive Heart Failure, for 12 consecutive days. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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. [...]