Advocate Healthcare Of East Boston, Llc

F-F882

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 70 of 72 225413 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225413 B. Wing 06/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Center at Advocate 111 Orient Avenue East Boston, MA 02128

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0882 Designate a qualified infection preventionist to be responsible for the infection prevent and control program in

the nursing home. Level of Harm - Minimal harm or potential for actual harm 48671

Residents Affected - Many Based on interviews and review of the Facility Assessment, the facility failed to designate one or more individuals as the infection preventionist who are responsible for the facility's infection prevention and control plan. Specifically, the facility failed to have a qualified infection preventionist with completed specialized training in infection prevention and control.

Findings include:

Review of the Facility Assessment, updated and reviewed with QAPI Committee, dated, March 2024 indicated the following:

-Facility resources need to provide competent support and care for our resident population every day and

during emergencies.

-Infection Control and Preventionist.

-Staff training / education and competencies programs are reviewed and revised to ensure we provide the level and types of support and care needed for our resident population. Include staff certification requirements as applicable.

-The facility evaluates our infection prevention and control program on a routine basis and as needed. The interdisciplinary team includes but is not limited to SDC (Staff Development Coordinator), DNS (Director of Nursing Services), ADNS (Assistant Director of Nursing), Administrator, Medical Director and lab. Effective systems for this team ensure the facility is preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement, that follow accepted national standards and local standards.

During an interview on 6/4/24 at 4:21 P.M., the Director of Nursing (DON) said she understands the importance of the infection prevention program and has been covering this role since the end of April 2024.

The DON said she does not have the required infection control certification and the facility does not have an approved infection preventionist working in the facility.

During an interview on 6/5/24 at 10:11 A.M., the Medical Director said he expects the facility to have an infection preventionist in the building managing the infection control program

During an interview on 6/5/24 at 1:25 P.M., the Administrator said he was aware that the facility did not have

an infection preventionist in the building.

During an interview on 6/10/24 at 1:04 P.M., the Regional Nurse said she was the regional nurse for this facility but could not speak to the specific infection prevention program in the building. The Regional Nurse said they do not currently have an infection preventionist in the building.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 71 of 72 225413 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225413 B. Wing 06/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Center at Advocate 111 Orient Avenue East Boston, MA 02128

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36876 potential for actual harm Based on observation, record review and interview, the facility failed to ensure the call light was accessible Residents Affected - Few for one Resident (#79) out of a total of 38 sampled residents.

Findings include:

Review of the facility's Call lights: Accessibility and Timely Response policy, dated February 2023 indicated: Staff will ensure the call light is within reach of resident and secured as needed. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.

Resident #79 was admitted to the facility in December 2021 with diagnoses including dementia, cerebrovascular accident (stroke) and depression.

Review of Resident #79's Minimum Data Set assessment dated [DATE REDACTED] indicated he/she scored 15 out of 15

on the Brief Interview of Mental Status Exam indicating intact cognition. The MDS also indicated that Resident #79 requires assistance with bathing, dressing and transfers.

On 6/4/24 at 8:52 A.M., the surveyor observed Resident #79 laying in bed with his/her call light inaccessible and out reach, on the floor behind his/her bed.

On 6/4/24 at 12:19 P.M., and 1:36 P.M., the surveyor observed Resident #79 laying in bed with his/her call light inaccessible and out of reach on the floor behind his/her bed.

On 6/6/24 at 2:02 P.M., the surveyor observed Resident #79 laying in bed. Resident #79 said he/she did not have a way to call out of help or assistance if he/she needed it. The surveyor observed Resident #79's call light inaccessible and out of reach on the floor behind his/her bed.

Review of Resident #79's fall care plan, dated 3/15/24, indicated an intervention to be sure Resident #79's call light is within reach.

During an interview on 6/6/24 at 2:05 P.M., Unit Manager #2 said call lights should be within reach and accessible for all residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 72 of 72 225413