Luxor Nursing & Rehabilitation at Mills Pond

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 1/7/2025 and completed on 1/14/2025, the facility did not ensure each resident was served food and drinks that were palatable, attractive, and at a safe and appetizing temperature. This was identified for ten (Resident #186, Resident #197, Resident # 52, Resident # 16, Resident #142, Resident #200, Resident #50, Resident #12, Resident #128, and Resident #164) of ten residents during the Resident Council meeting. Specifically, during the Resident Council meeting held on 1/8/2025, ten of the ten residents in attendance complained of hot food being served at cold temperatures. On 1/13/2025, during the lunch meal service, three (Unit 1 North, Unit 2 North, and Unit 3 South) of three units' meals temperatures for the hot food items were recorded below 135 degrees Fahrenheit. The finding is: [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 1/7/2025 and completed on 1/14/2025, the facility did not distribute and serve food in accordance with professional standards for food service safety. This was identified during the dining facility task and for ten (Resident #186, Resident #197, Resident # 52, Resident # 16, Resident #142, Resident #200, Resident #50, Resident #12, Resident #128, and Resident #164) of ten residents during the Resident Council meeting. Specifically, on 1/13/2025 during the lunch meal service, three (Unit 1 North, Unit 2 North, Unit 3 South) of three units meals temperatures for the hot food items were below 135 degrees Fahrenheit. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 1/7/2025 and completed on 1/14/2025, the facility did not ensure that an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infection was implemented. This was identified for one (Resident #208) of six residents reviewed for Infection Control. Specifically, Resident #208 had a physician's order for contact precautions secondary to Conjunctivitis (eye infection). On 1/13/2025, Occupational Therapist #1 and Physical Therapy Assistant #1 were observed ambulating the resident without proper Personal Protective Equipment. The finding is: [...]

Inspectors wroteBased on observation, record review and interviews during the Recertification Survey initiated on 7/5/2023 and completed on 7/13/2023 the facility did not ensure that each resident is treated with respect and dignity and is cared for in a manner that promotes maintenance or enhancement of his or her quality of life. This was identified for two (Resident #129 and Resident #95) of two residents reviewed for dignity. Specifically, 1) Certified Nursing Assistant (CNA) #3 was observed abruptly wheeling Resident #129 into the bathroom without informing the resident before moving their wheelchair. Resident #129 was startled. 2) CNA #3 was again observed to abruptly move another resident (Resident #95) in bed onto their left side to position the resident for wound care. CNA #3 did not explain or alert the resident before moving the resident. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 7/05/2023 and completed on 7/13/2023, the facility did not develop and implement a Comprehensive Person- Centered Care Plan (CCP) for each resident that includes measurable objectives and time frames to meet a resident's nursing needs. This was identified for one (Resident #136) of two residents reviewed for Accident Hazards. Specifically, Resident #136 had no CCP developed for the independent use and storage of large nail clippers. The finding is: The Care Plans-Comprehensive Policy, revised 10/2019 documented that a comprehensive, person-centered care plan (CCP) is developed within seven days of the completion of the required comprehensive assessment. Assessment of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 7/5/2023 and completed on 7/13/2023, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the initial tour of the kitchen on 7/5/2023. Specifically, emergency dry food and food products delivered to the facility without expiration dates were not tracked. The safety of consumption and discard dates of these food products were not determined as per the manufacturer's recommendations. The finding is: The facility's policy titled Food Safety - Food Handling dated 4/2017 documented that the facility only accepts prepared foods from suppliers subject to federal, state, or local food service inspections and who remain in good standing with such agencies. [...]

Inspectors wroteBased on observation, record review and interviews during the Recertification Survey initiated on 7/5/2023 and completed on 7/13/2023, the facility did not ensure that an infection prevention and control program (IPCP) designed to help prevent the development and transmission of communicable disease and infection was maintained. This was identified for one (Resident #95) of two residents reviewed for Pressure Ulcers. Specifically, during a wound care observation conducted on 7/12/2023 with Licensed Practical Nurse (LPN) #5, the LPN did not follow proper technique during cleansing of the wounds. LPN #5 did not clean each wound from the inner aspect towards the outer aspect of the wound and did not use new gauze for each cleansing of the wounds. The finding is: [...]

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey completed on 5/13/2021, the facility did not ensure that residents were receiving care and services in accordance with each resident's plan of care. This was identified for one (Resident #158) of two residents reviewed for Quality of Care concerns. Specifically, Resident #158 had a Physician's order for an ACE wrap to be applied on the 11 PM-7 AM shift. However, on two separate observations the ACE wraps were not in place to the resident lower extremities, and The finding is: Resident #158 was admitted to the facility with diagnoses that include Congestive Heart Failure and Renal Insufficiency. A Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score as 9, which indicated moderate cognitive impairment. [...]

Inspectors wroteBased on record review, and staff interviews during the Recertification Survey completed on 5/13/2021, the facility did not ensure that each residents' Comprehensive Care Plan was updated to reflect the residents' current status for one (Resident #193) of two residents reviewed for Activities of Daily Living (ADL). Specifically, Resident #193 had a Physician's order to be transferred out of bed with a Hoyer Lift (Mechanical Lift) and 2 staff members assistance. The Comprehensive Care Plan (CCP) and the Certified Nursing Assistant (CNA) Task record (directions for the CNAs to provide care to the resident) were not updated with the resident's current Physician orders. The finding is: Resident #193 was admitted to the facility with diagnoses that include Abnormalities of Gait and Mobility, Peripheral Vascular Disease, and Right Bundle Branch Block. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey completed on 05/13/2021 the facility did not ensure that medication irregularities reported by the Consultant Pharmacist were reviewed and acted upon by the Physician for 2 (Resident #47 and #163) of 5 residents reviewed for unnecessary medications. Specifically, the Consultant Pharmacist made recommendations to the Physician and a decision to agree or disagree to the recommendation was not documented by the Physician.

Inspectors wroteBased on observation, interview, and record review during the recertification survey completed on 05/13/2021, the facility failed to establish and maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19 for 1 out of 5 residents. Specifically, the facility did not have appropriate signage for a resident (#406) who was on Transmission-Based Precautions. Additionally, the facility staff did not wear required Personal Protective Equipment (PPE) while applying a pain patch to Resident #406's back. The finding is: The Centers for Disease Control and Prevention (CDC) guidance titled Transmission-Based Precautions (undated), provides: Use personal protective equipment (PPE) appropriately, including gloves and gown. [...]