Inspection Reports for Luxor at Mills Pond Rehabilitation & Nursing Center
273 Moriches Rd, St James, NY 11780, NY, 11780
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
82% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jan 14, 2025
Visit Reason
The inspection was a Recertification Survey initiated on 2025-01-07 and completed on 2025-01-14 to assess compliance with regulatory standards for nursing home operations, including food service and infection control.
Findings
The facility failed to ensure that hot food was served at safe and appetizing temperatures, with multiple units serving hot food below 135 degrees Fahrenheit. Additionally, the facility did not implement an effective infection prevention and control program, as staff ambulated a resident on contact precautions without proper personal protective equipment.
Deficiencies (3)
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
Report Facts
Residents affected: 10
Meal temperature: 128.5
Meal temperature: 124
Meal temperature: 108.1
Meal temperature: 131
Meal temperature: 120
Meal temperature: 120
Meal temperature: 100
Meal temperature: 110
Metal pellets: 200
Metal pellets ideal: 250
Residents reviewed for infection control: 6
Residents affected by infection control deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Occupational Therapist #1 | Occupational Therapist | Observed ambulating Resident #208 without PPE and interviewed regarding infection control breach |
| Physical Therapy Assistant #1 | Physical Therapy Assistant | Observed ambulating Resident #208 without PPE and interviewed regarding infection control breach |
| Food Service Director | Food Service Director | Interviewed about food temperature concerns and kitchen equipment issues |
| Administrator | Administrator | Interviewed about resident complaints and kitchen equipment replacement plans |
| Director of Nursing Service | Director of Nursing Service | Interviewed regarding infection control breach by therapy staff |
| Infection Control Preventionist | Infection Control Preventionist | Interviewed regarding infection control policy and breach by therapy staff |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 9
Date: Jan 14, 2025
Visit Reason
Inspection identified 3 standard health deficiencies and 6 life safety code deficiencies, all Level 2 severity, corrected by February 25, 2025.
Findings
Inspection identified 3 standard health deficiencies and 6 life safety code deficiencies, all Level 2 severity, corrected by February 25, 2025.
Deficiencies (9)
Food procurement,store/prepare/serve-sanitary
Infection prevention & control
Nutritive value/appear, palatable/prefer temp
Building construction type and height
Emergency lighting
Hazardous areas - enclosure
Maintenance, inspection & testing - doors
Sprinkler system - maintenance and testing
Subdivision of building spaces - smoke barrie
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 8
Date: Jul 13, 2023
Visit Reason
Inspection identified 4 standard health deficiencies and 4 life safety code deficiencies, all Level 2 severity, corrected by August 2023.
Findings
Inspection identified 4 standard health deficiencies and 4 life safety code deficiencies, all Level 2 severity, corrected by August 2023.
Deficiencies (8)
Develop/implement comprehensive care plan
Food procurement,store/prepare/serve-sanitary
Infection prevention & control
Resident rights/exercise of rights
Electrical systems - essential electric syste
Fire alarm system - installation
Fire alarm system - testing and maintenance
Subdivision of building spaces - smoke barrie
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jul 12, 2023
Visit Reason
The Recertification Survey was initiated on 7/5/2023 and completed on 7/13/2023 to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, incomplete comprehensive care plans for resident safety, improper food storage and expiration date tracking, and inadequate infection prevention and control practices during wound care.
Deficiencies (4)
Failure to ensure residents were treated with dignity and respect, including abrupt movements without explanation causing residents to be startled.
Failure to develop and implement a comprehensive person-centered care plan for resident's independent use and storage of large nail clippers.
Failure to ensure food was stored, prepared, distributed, and served in accordance with professional standards, including lack of tracking expiration dates for emergency dry food and canned goods.
Failure to maintain an infection prevention and control program, specifically improper wound cleansing technique by Licensed Practical Nurse.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Expiration dates: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nursing Assistant | Named in findings related to abrupt movements of residents without explanation |
| LPN #5 | Licensed Practical Nurse | Named in wound care observation for improper cleansing technique |
| Director of Nursing Services | DNS | Interviewed regarding staff education and deficiencies |
| Assistant Director of Nursing Services | ADNS/Staff Educator | Interviewed regarding staff education on dignity and communication |
| Director of Social Services | DSS #1 | Interviewed regarding resident nail clipper use and care plan |
| Licensed Practical Nurse | LPN #6 | Interviewed regarding implementation of care plan for nail clipper use |
| Food Services Director | FSD | Interviewed regarding food storage and expiration date tracking deficiencies |
| Dietary Aide | DA #1 | Interviewed regarding food receiving and stocking practices |
| Wound Care Registered Nurse | RN #2 | Interviewed regarding wound care competency evaluations |
| Administrator | Interviewed regarding expired food items and corrective actions |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: May 13, 2021
Visit Reason
The inspection was a Recertification Survey conducted to assess compliance with regulatory requirements and quality of care standards at Luxor Nursing and Rehabilitation at Mills Pond.
Findings
The facility was found deficient in multiple areas including failure to ensure residents received care according to their care plans, incomplete updates to comprehensive care plans reflecting current physician orders, lack of physician response to pharmacist medication recommendations, and inadequate infection prevention and control practices related to COVID-19 precautions.
Deficiencies (4)
Failure to ensure residents received care and services in accordance with each resident's plan of care, specifically Resident #158 did not have ACE wraps applied as ordered.
Failure to update the comprehensive care plan within 7 days of the comprehensive assessment to reflect current physician orders for Resident #193 requiring Hoyer Lift and two staff assistance for transfers.
Failure to ensure medication irregularities reported by the Consultant Pharmacist were reviewed and acted upon by the Physician for Residents #47 and #163.
Failure to provide and implement an infection prevention and control program, including lack of appropriate signage and failure of staff to wear required PPE while applying a pain patch to Resident #406 on Transmission-Based Precautions.
Report Facts
Residents reviewed for Quality of Care concerns: 2
Residents reviewed for unnecessary medications: 5
Physician's order date: Jan 15, 2021
Physician's order date: Apr 7, 2021
Pharmacist consult note date: Apr 9, 2021
Pharmacist consult note date: Mar 29, 2021
Physician's order date: May 12, 2021
Transmission-Based Precautions duration: 14
BIMS score: 9
BIMS score: 9
BIMS score: 14
BIMS score: 9
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Interviewed regarding lack of awareness of ACE wrap order for Resident #158 |
| LPN #2 | Licensed Practical Nurse | Interviewed about ACE wrap treatment order visibility and application for Resident #158 |
| LPN #3 | Licensed Practical Nurse | Applied ACE wraps to Resident #158 and removed them due to juice spill, did not inform day shift nurse |
| Director of Nursing Service | Director of Nursing Services (DNS) | Interviewed multiple times regarding deficiencies in care plan implementation, medication review, and infection control |
| CNA #6 | Certified Nursing Assistant | Interviewed about Resident #193's assistance needs post-hospitalization |
| CNA #7 | Certified Nursing Assistant | Interviewed about Resident #193's transfer assistance needs |
| Physical Therapy Assistant | PTA | Interviewed about Resident #193's transfer status and therapy |
| Certified Occupational Therapy Assistant | COTA | Interviewed about Resident #193's transfer status and therapy |
| Physical Therapist | PT | Interviewed about Resident #193's transfer assessment |
| Physician | Attending Physician | Interviewed regarding delayed response to pharmacist recommendations |
| LPN medication nurse | Licensed Practical Nurse | Observed and interviewed regarding PPE use while applying pain patch to Resident #406 |
| Registered Nurse Infection Preventionist | RN Infection Preventionist (IP) | Interviewed about PPE requirements for residents on Transmission-Based Precautions |
| RN Staff Educator | Staff Educator | Interviewed about staff education on PPE use and signage for COVID-19 precautions |
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