Neville Center at Fresh Pond for Nursing & Rehab

In the surveyor’s words

From the most serious findings on record at Neville Center at Fresh Pond for Nursing & Rehab, in the surveyor’s own words.

• Actual harm, isolatedF686May 19, 2022

  Based on record review, interview and observation, the facility failed to prevent the deterioration of a pressure injury to 1 Resident (#74), out of 33 sampled residents. Findings include: Review of Resident #74's medical record indicated that on 5/10/22, the Wound Physician identified a new pressure injury located on the coccyx and recommended interventions for treatment which included: daily calcium alginate dressing changes covered in gauze, off-load the wound, reposition per facility protocol, and use of a Group 2 mattress. […]

• No harm, potential for more than minimal, patternF812May 13, 2026

  Based on observation and interview, the facility failed to store and handle food in accordance with professional standards for food service safety, potentially putting the residents at risk for foodborne illness. Specifically, 1. The facility failed to ensure that food was stored, labeled, and dated properly, and that food/beverages were not expired and personal drinks were not stored in the kitchen refrigerator.2. The facility failed to ensure staff wore beard coverings and staff did not handle ready-to-eat food with contaminated gloves.3. The facility failed to consistently monitor the effective use of a low temperature manual chemical sanitization station and failed to document the parts per million (PPM) of the sanitizing solution, to ensure effective sanitization. […]

• No harm, potential for more than minimal, patternF677May 19, 2022

  Based on observations, interviews and record reviews, the facility failed to provide assistance with meals for 4 Residents (#58, #60, #79 and #96) out of a total sample of 33 residents. Findings include: Review of the facility policy titled, ADL Support Guideline dated 8/10/17, indicated the following: *Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLS). *Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 1. […]

• No harm, potential for more than minimal, patternF812May 19, 2022

  Based on observation, record review, and interview, the facility failed to 1) maintain proper sanitation practices in the kitchen and 2) maintain proper sanitation processes while serving breakfast. Findings include: 1. On 5/17/2022 at 7:28 A.M., the following observations were made during the initial kitchen walk-through: *5 boxes containing food items were stored on the freezer floor 2. On 5/19/2022 starting at 7:30 A.M. the following observations were made during breakfast meal service: * The cook was observed touching utensils, plates, and bowls with a gloved hand, contaminating them, and with the same contaminated gloved hand, peeled ready-to-eat hard boiled eggs 4 times which were then served on resident's trays. […]

• No harm, potential for more than minimal, patternF880May 19, 2022

  Based on observation, record and policy review the facility failed to ensure that personal protection equipment, specifically facemasks were worn by staff as required and failed to perform hand hygiene during dressing changes for 2 Residents (#65 and #74) Findings include: Review of the facility policy titled Hand Hygiene/Hand Washing Guidelines and dated August 5, 2014, indicated that hand hygiene is performed prior to taking part in any medical procedure and after removal of medical/surgical gloves. 1. […]