Neville Center at Fresh Pond for Nursing & Rehab

Inspectors wroteBased 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.

Inspectors wroteBased on observation, record reviews and interviews, the facility failed to ensure that one Resident (#74) was provided with treatment and care to maintain good foot health, out of a total sample of 21 residents. Specifically for Resident #74 who was last seen by the podiatrist on 2/12/26, and the podiatrist recommended that Resident #74 be seen as medically necessary but no sooner than 60 days, the facility failed to ensure the Resident was seen on 5/4/26, when his/her nails needed services.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure medications were stored as required for one Resident (#78), out of a total sample of 21 residents. Specifically, the facility failed to ensure that medications were not left at the bedside for Resident #78 while unsupervised by staff.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to consistently accommodate resident food allergies, intolerances, and preferences for two Resident (#42 and #104) out of a total sample of 21 residents. Specifically,1. For Resident #42, who had allergies listed as wheat and lactose, the facility served the Resident French toast, bacon (a dislike), a cookie containing wheat and milk, and scrambled eggs with cheese.2. For Resident #104, who required a vegan (diet that avoids all animal derived products such as meat and dairy) diet and had dairy listed as a dislike, the facility served Resident #104 half and half creamers containing dairy on three occasions.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure all equipment is maintained in safe operating condition. Specifically, 1. The facility failed to ensure the grease trap was maintained according to manufacturer's recommendations.2. The facility failed to ensure the two bays of the three-bay sink were in safe operating condition.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide necessary treatment, services, interventions to promote healing and prevent new pressure ulcers from developing for two Residents (#3 and #60) out of 19 total sampled residents. Specifically, 1.) For Resident #3, who had a left heel pressure ulcer, the facility failed to implement booties (heel offloading devices which are designed to prevent and treat pressure ulcers) as ordered by the physician. 2.) For Resident #60, who had a history of a heel pressure ulcer, the facility failed to implement booties as ordered by the physician.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to adequately maintain the nutrition and hydration status of two Residents (#8 and #28) out of a total sample of 19 residents. Specifically, 1. For Resident #8,the facility failed to follow up on a significant weight change. 2. For Resident #28,the facility failed to follow a physician's order for a fluid restriction.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC), consistent with professional standards of practice for one Resident (#60), out of a total sample of 19 residents. Specifically, for Resident #60, the facility failed to implement a physician's order for weekly routine PICC dressing changes, as required.

Inspectors wroteBased on policy review, observation and staff interview, the facility failed to ensure pharmaceutical services met the needs of each resident. Specifically, the facility failed to ensure insulin and intravenous emergency kits were replaced by the pharmacy after being opened on two out of three units.

Inspectors wroteBased on observations and interviews the facility failed to ensure drugs and biologicals were stored in accordance with acceptable professional standards of practice. Specifically, nursing failed to ensure medications were dated once opened, and stored according to manufacturer's guidelines, in one of three medication carts observed.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to accurately document in the medical record for two Residents (#60 and #3) out of 19 total sampled residents. Specifically, 1.) For Resident #60, the nurses inaccurately documented: a.) a peripherally inserted central catheter (PICC) dressing change as being completed when it was not; b.) heel booties (heel offloading devices which are designed to prevent and treat pressure ulcers) as being implemented when they were not; and c.) side rails were padded when they were not. 2.) For Resident #3, the nurses inaccurately documented heel booties being implemented and heels being offloaded when they were not.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had an activated Health Care Proxy, and upon admission had given signed consent for him/her to be administered the COVID-19 Vaccination, the Facility failed to ensure he/she was given the vaccine, increasing Resident #1 risk for acquiring the infection.

Inspectors wroteBased on observation and interview, the facility failed to provide residents with a dignified dinning experience on one of three units.

Inspectors wroteBased on record review and interview, the facility failed for one Resident (#81) of 25 sampled residents, to develop a baseline care plan to address his/her risk for falls.

Inspectors wroteBased on observation, record review and interview the facility failed to develop a dental care plan for one Resident (#87) out of 25 sampled residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure the environment was free from hazards that could cause accidents for one Resident (#79) out of a sample of 25 Residents. Specifically, the facility failed to pad the Resident's side rails as ordered.

Inspectors wroteBased on interviews, policy review and observations, the facility failed to secure medication on one of three units (second floor).

Inspectors wroteBased on records reviewed and interviews for two Residents (#87 and #89) out of a total sample of 25, the facility failed to provide dental care. Specifically: 1. For Resident #87, who had broken/carious teeth and lost his/her lower dentures, the facility failed to ensure he/she had a timely dental consultation. 2. For Resident #89, the facility failed to follow up on the recommendation for the fabrication of the upper dentures, three months after originally recommended. Findings Include: Review of the facility policy titled Dental Care guideline dated 5/23/18, indicated the following: The facility will if necessary or requested, assist the resident with making appointments or arrange dental services. A dentist will be made available for each resident through a contractual agreement by an approved dental provider that services the center or from the community. 1. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain accurate medical records in accordance with professional standards and practices for two Residents (#87 and #79) out of a total sample of 25 residents. Specifically: 1. For Resident #87, the facility failed to accurately document the dental status on the nursing admission assessment, 2. For Resident #79, the facility failed to accurately document the presence of side rail pads after Resident #79's room change.