The Center At Advocate

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/19/2025

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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

injury (DTI) with eschar (dead tissue and unstageable).Review of Resident #3's Podiatry Note, dated 10/27/25, indicated he/she had eschars to bilateral heels.Review of Resident #3's Weekly Skin Assessments, dated 09/30/25, 10/07/25, 10/14/25, 10/21/25, 10/28/25, 11/05/25, 11/11/25, and 11/18/25, indicated that there was no documentation to support nursing staff had observed any skin impairments to his/her heels.Review of Resident #3's Weekly Skin Assessments, dated 11/25/25, 12/02/25, 12/10/25, and 12/16/25, indicated that there was no documentation to support nursing measured or monitored the progress and/or deterioration of his/her bilateral heel pressure injuries.Review of Resident #3's Nurse Progress Notes and Treatment Administration Records (TAR), dated September 2025 through December of 2025, indicated there was no documentation to support nursing staff were measuring or monitoring the affected areas.During a telephone interview on 12/31/25 at 1:32 P.M., the Staff Development Coordinator said that any resident that has pressure injury must have measurements completed weekly on the resident's skin assessment form. 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/19/2025

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 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed, interviews, and observations for one of three sampled residents (Resident #3) who required Enhanced Barrier Precautions (EBP-an infection control intervention designed to reduce transmission of Multi-Drug-Resistant Organisms (MDRO) in nursing homes) related to wound care needs,

the Facility failed to ensure nursing staff were aware of when to use and implement the necessary infection control practices during the provision of care. Findings include:Review of the Facility's Policy titled Enhanced Barrier Precautions (EBP) dated as last revised 09/2024, indicated that EBP's are utilized for the prevention of transmission of multi-drug-resistant organisms (MDRO's) to residents.The Policy further indicated that a physician's order for EBP's will be obtained for residents with any of the following:-Wounds (chronic wounds such as pressure injuries, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers); and/or-Indwelling medical devices (central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO.-PPE for EBP's is only necessary when performing high-contact care activities (dressing, bathing, transferring, providing hygiene, changing linens, briefs, toileting, device care and wound care)Resident #3 was admitted to the Facility in 09/2025, diagnoses include dementia with behaviors, repeated falls, and depression.Review of Resident #3's, admission assessment dated [DATE REDACTED], indicated that he/she was admitted with two (2) Stage 2 (partial thickness skin loss where the outer layer and part of the underlying dermis is damaged) pressure injuries, one to each of his/her heels.Review of Resident #3's admission Minimum Data Set (MDS) Assessment, dated 09/30/25, indicated he/she had two Stage 2 pressure injuries present on admission.During an interview on 12/31/25 at 1:32 P.M., the Infection Preventionist (IP) said that she was not aware that Resident #3 had two pressure injuries upon admission.The IP said that if a resident is admitted with or develops a pressure injury nursing staff must notify her and initiate EBP's (put a sign at their room door and provide PPE outside of the room) to help minimize the spread of any infection.Review of Resident #3's Physician's Orders, dated 12/19/25, indicated that there was no documentation to support that a Physician's Order had been obtained to maintain EBP's (until after being identified by the Surveyor during the survey).During an observation on 12/19/25 at 9:36 A.M., the Surveyor observed that there was no signage on Resident #3's room outside the doorway to indicate that he/she was on any kind of precautions and there was no Personal Protective Equipment (PPE- gowns, gloves, masks, eye protection) designated to his/her room. 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.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet