LUXOR NURSING AND REHABILITATION AT MILLS POND Nursing Home


LUXOR NURSING AND REHABILITATION AT MILLS POND (CCN: 335739) is a For profit - Corporation facility located in ST JAMES, NY (11780). The facility has an overall rating of 4/5, health inspection rating of 4/5, and a staffing rating of 1/5. It offers 252 certified beds and maintains an average of 219. residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 3.60374 total hours per resident per day. It has been certified since August 21, 1991 and the last listed health inspection was on July 13, 2023, The facility is located in Suffolk county and provides senior and nursing home care.

LUXOR NURSING AND REHABILITATION AT MILLS POND Summary


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Provider Name: LUXOR NURSING AND REHABILITATION AT MILLS POND

Address: 273 MORICHES ROAD, ST JAMES, NY 11780

Phone: (631) 862-8990

County: Suffolk (700)

Ownership Type: For profit - Corporation

Certified Beds: 252

Average Residents Per Day: 219. ()

Provider Type: Medicare and Medicaid, Resides in Hospital: No

Legal Business Name: S&J OPERATIONAL LLC

First Approved Date: August 21, 1991

Affiliated Entity: ()

Retirement Community: N, Special Focus Status:

Ownership Change in Last 12 Months: N

Resident Family Council: Both

Sprinkler System Status: Yes

Overall Rating: 4 ()

Health Inspection Rating: 4 ()

QM Rating: 5 ()

Long Stay QM Rating: 5 ()

Short Stay QM Rating: 5 ()

Staffing Rating: 1 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 2.25668, LPN Staff Hours Per Day: 1.0230, RN Staff Hours Per Day: 0.3240, Licensed Staff Hours Per Day: 1.3470

Total Nurse Staff Hours Per Day, per resident: 3.60374

Weekend Nurse Staff Hours: 3.20536, Weekend RN Staff Hours: 0.1566

PT Staff Hours Per Day, per resident: 0.1997

Nurse Staff Turnover: 38.3, Nurse Turnover Note:

RN Turnover: 53.8, RN Turnover Note:

Admin Left Number: 1, Admin Turnover Note:

Case Mix Nurse Aide Hours Per Day, per resident: 2.2066, Case Mix LPN Hours Per Day: 0.9515, Case Mix RN Hours Per Day: 0.5686

Adjusted Nurse Aide Hours Per Day, per resident: 2.08348, Adjusted LPN Hours Per Day: 0.7934, Adjusted RN Hours Per Day: 0.2147

Total Adjusted Nurse Hours Per Day, per resident: 3.04801

Adjusted Weekend Nurse Hours Per Day, per resident: 2.71107

Health Survey Dates and Scores: Cycle 1: 2023-07-13 (Score: 16), Cycle 2: 2021-05-13 (Score: 16), Cycle 3: 2019-02-15 (Score: 4)

Total Weighted Health Score: 14.000

Reported Incidents: 0, Substantiated Complaints: 0

Infection Control Citations: 0

Fines and Penalties: Number of Fines: 0, Total Fines in Dollars: 0.00, Payment Denials Number: 0, Total Penalties Number: 0

Location and GPS: 273 MORICHES ROAD,ST JAMES,NY,11780 (40.8789, -73.142)

Process Date: 2024-03-01


Health Inspection Citations Details

Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2023-07-13

Type: Health, Deficiency: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-08-11

Citation on 2023-07-13

Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-08-11

Citation on 2023-07-13

Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-08-11

Citation on 2023-07-13

Type: Health, Deficiency: Provide and implement an infection prevention and control program.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-08-11

Citation on 2021-05-13

Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-07-10

Citation on 2021-05-13

Type: Health, Deficiency: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-07-10

Citation on 2021-05-13

Type: Health, Deficiency: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-07-10

Citation on 2021-05-13

Type: Health, Deficiency: Provide and implement an infection prevention and control program.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-07-10

Citation on 2019-02-15

Type: Health, Deficiency: Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-03-31


Fire Safety Citations Details

Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2023-07-19

Type: Fire Safety, Tag: 0341, Version: New

Description: Install a fire alarm system that can be heard throughout the facility.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-08-16

Citation on 2023-07-19

Type: Fire Safety, Tag: 0345, Version: New

Description: Have approved installation, maintenance and testing program for fire alarm systems.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-08-15

Citation on 2023-07-19

Type: Fire Safety, Tag: 0374, Version: New

Description: Install smoke barrier doors that can resist smoke for at least 20 minutes.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-08-23

Citation on 2023-07-19

Type: Fire Safety, Tag: 0918, Version: New

Description: Have generator or other power source capable of supplying service within 10 seconds.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-08-08

Citation on 2021-05-13

Type: Fire Safety, Tag: 0521, Version: New

Description: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-07-12

Citation on 2021-05-13

Type: Fire Safety, Tag: 0923, Version: New

Description: Have proper medical gas storage and administration areas.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-07-12

Citation on 2019-02-15

Type: Fire Safety, Tag: 0351, Version: New

Description: Install an approved automatic sprinkler system.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-04-05

Citation on 2019-02-15

Type: Fire Safety, Tag: 0353, Version: New

Description: Inspect, test, and maintain automatic sprinkler systems.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-04-05

Citation on 2019-02-15

Type: Fire Safety, Tag: 0374, Version: New

Description: Install smoke barrier doors that can resist smoke for at least 20 minutes.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-04-05

Citation on 2019-02-15

Type: Fire Safety, Tag: 0920, Version: New

Description: Ensure proper usage of power strips and extension cords.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-04-05