NEVILLE CENTER AT FRESH POND FOR NURSING & REHAB Nursing Home


NEVILLE CENTER AT FRESH POND FOR NURSING & REHAB (CCN: 225378) is a Non profit - Corporation facility located in CAMBRIDGE, MA (02138). The facility has an overall rating of 5/5, health inspection rating of 4/5, and a staffing rating of 4/5. It offers 112 certified beds and maintains an average of 106. residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 3.98294 total hours per resident per day. It has been certified since July 1, 1990 and the last listed health inspection was on June 8, 2023, The facility is located in Middlesex county and provides senior and nursing home care.

NEVILLE CENTER AT FRESH POND FOR NURSING & REHAB Summary


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Provider Name: NEVILLE CENTER AT FRESH POND FOR NURSING & REHAB

Address: 640 CONCORD AVENUE, CAMBRIDGE, MA 02138

Phone: (617) 497-0600

County: Middlesex (090)

Ownership Type: Non profit - Corporation

Certified Beds: 112

Average Residents Per Day: 106. ()

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

Legal Business Name: NEVILLE COMMUNITIES HOME INC

First Approved Date: July 1, 1990

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: 5 ()

Health Inspection Rating: 4 ()

QM Rating: 5 ()

Long Stay QM Rating: 5 ()

Short Stay QM Rating: 5 ()

Staffing Rating: 4 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 2.12535, LPN Staff Hours Per Day: 0.9512, RN Staff Hours Per Day: 0.9063, Licensed Staff Hours Per Day: 1.8576

Total Nurse Staff Hours Per Day, per resident: 3.98294

Weekend Nurse Staff Hours: 3.55014, Weekend RN Staff Hours: 0.4691

PT Staff Hours Per Day, per resident: 0.2730

Nurse Staff Turnover: 33.0, Nurse Turnover Note:

RN Turnover: 26.1, RN Turnover Note:

Admin Left Number: 1, Admin Turnover Note:

Case Mix Nurse Aide Hours Per Day, per resident: 2.2865, Case Mix LPN Hours Per Day: 0.7145, Case Mix RN Hours Per Day: 0.3449

Adjusted Nurse Aide Hours Per Day, per resident: 1.89359, Adjusted LPN Hours Per Day: 0.9825, Adjusted RN Hours Per Day: 0.9900

Total Adjusted Nurse Hours Per Day, per resident: 3.75202

Adjusted Weekend Nurse Hours Per Day, per resident: 3.34431

Health Survey Dates and Scores: Cycle 1: 2023-06-08 (Score: 24), Cycle 2: 2022-05-19 (Score: 64), Cycle 3: 2019-08-08 (Score: 12)

Total Weighted Health Score: 35.333

Reported Incidents: 0, Substantiated Complaints: 0

Infection Control Citations: 0

Fines and Penalties: Number of Fines: 3, Total Fines in Dollars: 34747.70, Payment Denials Number: 0, Total Penalties Number: 3

Location and GPS: 640 CONCORD AVENUE,CAMBRIDGE,MA,02138 (42.3896, -71.148)

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 2023-06-08

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 2023-06-20

Citation on 2023-06-08

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 2023-06-20

Citation on 2023-06-08

Type: Health, Deficiency: Provide care and assistance to perform activities of daily living for any resident who is unable.

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 2023-06-20

Citation on 2023-06-08

Type: Health, Deficiency: Provide enough food/fluids to maintain a resident's health.

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 2023-06-20

Citation on 2023-06-08

Type: Health, Deficiency: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

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 2023-06-20

Citation on 2023-06-08

Type: Health, Deficiency: Provide safe and appropriate respiratory care for a resident when needed.

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 2023-06-20

Citation on 2022-05-19

Type: Health, Deficiency: Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

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 2022-06-15

Citation on 2022-05-19

Type: Health, Deficiency: Ensure each resident receives an accurate assessment.

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 2022-06-15

Citation on 2022-05-19

Type: Health, Deficiency: Ensure services provided by the nursing facility meet professional standards of quality.

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 2022-06-15

Citation on 2022-05-19

Type: Health, Deficiency: Provide care and assistance to perform activities of daily living for any resident who is unable.

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 2022-06-15

Citation on 2022-05-19

Type: Health, Deficiency: Provide activities to meet all resident's needs.

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 2022-06-15

Citation on 2022-05-19

Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-06-15

Citation on 2022-05-19

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 2022-06-15

Citation on 2022-05-19

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

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 2022-06-15

Citation on 2022-05-19

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

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 2022-06-15

Citation on 2019-08-08

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 2019-08-30

Citation on 2019-08-08

Type: Health, Deficiency: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

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 2019-08-30

Citation on 2019-08-08

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 2019-08-30


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 2023-06-12

Type: Fire Safety, Tag: 0041, Version: New

Description: Implement emergency and standby power 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 2023-07-15

Citation on 2023-06-12

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 2023-07-15

Citation on 2023-06-12

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 2023-07-15

Citation on 2023-06-12

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 2023-07-15

Citation on 2022-05-31

Type: Fire Safety, Tag: 0311, Version: New

Description: Have an enclosure around a vertical opening shaft.

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

Corrected: Deficient, Provider has date of correction on 2022-07-02

Citation on 2022-05-31

Type: Fire Safety, Tag: 0761, Version: New

Description: To conduct inspection, testing and maintenance of fire doors by qualified individuals.

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

Corrected: Deficient, Provider has date of correction on 2022-07-02