Deficiency Records for Luxor Nursing and Rehabilitation at Mills Pond
Updated as of April 01, 2024
A list of the most recent deficiencies for Luxor Nursing and Rehabilitation at Mills Pond. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-07-19 | 2023-08-23 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-07-19 | 2023-08-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-19 | 2023-08-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-07-13 | 2023-08-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-13 | 2023-08-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-13 | 2023-08-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-13 | 2023-08-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-19 | 2023-08-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-05-13 | 2021-07-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-05-13 | 2021-07-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-13 | 2021-07-10 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-05-13 | 2021-07-10 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-05-13 | 2021-07-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-13 | 2021-07-10 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-02-15 | 2019-04-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-15 | 2019-04-05 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-02-15 | 2019-04-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-15 | 2019-04-05 | N |
| 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. | Health | 2019-02-15 | 2019-03-31 | N |
