The Center At Advocate
THE CENTER AT ADVOCATE in EAST BOSTON, MA — inspection on December 19, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
that she left Nurse #2 and CNA #1 in Resident #2's room while she ran to check his/her code status.
Nurse #1 said that she looked in Point Click Care (PCC, the Facility's Electronic Medical Record) at his/her face sheet and determined that he/she was a full code.
Nurse #1 said she called a Code Blue, returned to Resident #2's room and initiated CPR with Nurse #2 until EMS arrived and took over lifesaving needs.Nurse #1 said that it was not until after the EMS took over that she noticed the Former Director of Nurses (DON) with a pink MOLST Form in her hands informing EMS that Resident #1 was not a Full Code, but a DNR/DNI.During a telephone interview on 12/30/25 at 12:29 A.M., Nurse #2 said that she was the Nurse helping Nurse #1 with administering CPR to Resident #2.Nurse #2 said that when EMS arrived, she had gone to Resident #2's chart and located his/her MOLST Form indicating he/she was a DNR/DNI.
Nurse #2 said she immediately handed it to the former DON and that was when EMS announced to stop CPR, that Resident #2 was a DNR/DNI.
During an interview on 12/18/25 at 2:02 P.M., Certified Nurse Aide (CNA) #1 said that at 3:15 P.M., Resident #2 walked to the nurse's station from his/her room, and she noted that he/she was unsteady on his/her feet (which had been unusual). CNA #1 said that she, Nurse #1 and Nurse #2 walked Resident #2 back to his/her room and said they were trying to prevent him/her from laying down, but he/she laid down flat and almost instantly became unresponsive.CNA #1 said that one of the nurses said to call a code blue, everyone began arriving with the crash cart, Automatic Electronic Defibrillator, and she said she called Emergency Medical Services (EMS/911).
During an interview on 12/19/25 at 8:40 A.M., the Director of Social Services said that she had missed Resident #2's advanced directives and MOLST from upon admission and that Resident #2 had elected to be a DNR/DNI as his/her advanced directive.
During an interview on 12/19/25 at 1:24 P.M., the Director of Nurses (DON) said that it is the Facility's expectation that upon the identification of an unresponsive resident in need of emergency services such as CPR, the nurse and/or designee must physically see the resident's MOLST to determine their advanced directives.0n 12/19/25, the Facility presented the Surveyor with a plan of correction with an effective date of 11/21/25 that addressed the area of concern identified in this survey, as follows: A) Resident #2 had been pronounced dead at the Facility on 11/18/25.B) On 11/18/25, the incident was reviewed by the Director of Nurses, Assistant Director of Nurses, Nursing Supervisor, Administrator, and Medical Director via an Ad-[NAME] Quality Assurance and Performance improvement meeting.C) On 11/19/25, licensed staff directly involved with the incident were educated on Emergency access to MOLST Forms and verification of code status during emergencies.D) On 11/19/25, the Administrator, Nurse Managers, and Social Services completed a Facility wide audit of all current residents with a MOLST or Advanced Directives in place, ensuring accuracy of code status, physician's orders, Point Click Care (PCC) Electronic Medical Record (EMR), and prompt scanning of forms into the EMR.E) On 11/19/25, the Staff Development Coordinator (SDC) and DON initiated mandatory education for facility staff (NSG, SS, Physician's) regarding Code Status Verification and Emergency Response by staff. F) Effective 11/19/25, Social Services and Nursing Managers will audit 10 random resident records weekly to review for compliance, they will do this for 4 months, and then for two more months or until 100 percent compliance is met.G) On 11/25/25, the Facility reviewed the POC at their scheduled QAPI meeting.H).
The Administrator, the (new) Director of Nurses and/or their designees are responsible for overall compliance.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
The Center at Advocate
111 Orient Avenue East Boston, MA 02128
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 12/19/25 at 12:51 P.M., the Assistant Director of Nurses said that if a Nurse receives any recommendations from a provider, including an outpatient wound clinic, the recommendations must be reviewed with the resident's physician for either approval or denial immediately.
During an interview on 12/19/25 at 1:24 P.M., the Director of Nurses (DON) said she was unaware that Resident's #1 and #3's wounds were not being measured weekly or that their wound care recommendations had not been reviewed by their attending physician's.The DON said that it is the Facility's expectation that all recommendations received by a third-party provider must be reviewed with the resident's attending physician. If the recommendations are approved, nursing will obtain a physician's order timely.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
The Center at Advocate
111 Orient Avenue East Boston, MA 02128
SUMMARY STATEMENT OF DEFICIENCIES
During the same observation the Surveyor observed two Certified Nurse Aides (CNA) in Resident #3's room providing direct care for him/her without wearing the appropriate PPE.
During an interview on 12/19/25 at 10:05 A.M., CNA #2 said that Resident #3 was not on any precautions that she was aware of, that she had provided Resident #3 personal care in the morning and had not worn PPE other than gloves.
During an interview on 12/19/25 at 10:16 A.M., Nurse #4 said that Resident #3 has a pressure injury to his/her left heel that was open and bleeding.
Nurse #4 said that he/she should be on EBP's.
Nurse #4 said she was not sure why there was no sign for EBP's outside of his/her room.
During an interview of 12/19/25 at 1:24 P.M., the Director of Nurses (DON), said she did not know Resident #3 was not placed on EBP's and said he/she should have been secondary to his/her pressure injury, wound care needs.The DON said that it was the Facility's expectation that any resident with a history of an MDRO, indwelling device, and wounds, that they must be placed on EBP's immediately, and also be reported to her and the IP to ensure proper infection control procedures are being followed.
Facility ID: