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Deficiency Records for Advocate Healthcare of East Boston, LLC
A list of the most recent deficiencies for Advocate Healthcare of East Boston, LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Advocate Healthcare of East Boston, LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-06-21 | 2024-07-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-06-10 | 2024-06-27 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-06-10 | 2024-06-27 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-06-10 | 2024-06-27 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-06-10 | 2024-06-27 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-06-10 | 2024-06-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-06-10 | 2024-06-27 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-06-10 | 2024-06-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-06-10 | 2024-06-27 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-06-10 | 2024-06-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-10 | 2024-06-27 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-06-10 | 2024-06-27 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-06-10 | 2024-06-27 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-06-10 | 2024-06-27 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-06-10 | 2024-06-27 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-06-10 | 2024-06-27 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-06-10 | 2024-06-27 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2024-06-10 | 2024-06-27 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-06-10 | 2024-06-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-06-10 | 2024-06-27 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-06-10 | 2024-06-27 | N |
| 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. | Health | 2024-06-10 | 2024-06-27 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-06-10 | 2024-06-27 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-06-10 | 2024-06-27 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2024-06-10 | 2024-06-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-06-10 | 2024-06-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-06-10 | 2024-06-27 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-06-10 | 2024-06-27 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-06-10 | 2024-06-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-08 | 2023-05-26 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-05-08 | 2023-05-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-08 | 2023-05-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-08 | 2023-05-26 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-04-26 | 2023-05-22 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-26 | 2023-05-22 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-26 | 2023-05-22 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-04-26 | 2023-05-22 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-26 | 2023-05-22 | N |
| Respond appropriately to all alleged violations. | Health | 2023-04-26 | 2023-05-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-04-26 | 2023-05-22 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-04-26 | 2023-05-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-26 | 2023-05-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-26 | 2023-05-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-26 | 2023-05-22 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-04-26 | 2023-05-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-26 | 2023-05-22 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-04-26 | 2023-05-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-26 | 2023-05-22 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-04-26 | 2023-05-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-04-26 | 2023-05-22 | N |
| Provide or obtain dental services for each resident. | Health | 2023-04-26 | 2023-05-22 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-04-26 | 2023-05-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-26 | 2023-05-22 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-03-07 | 2022-04-20 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-03-07 | 2022-04-20 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-03-07 | 2022-04-20 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-03-07 | 2022-04-20 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2022-03-07 | 2022-04-20 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-03-07 | 2022-04-20 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-03-07 | 2022-04-20 | N |
| Develop a communication plan. | Fire Safety | 2022-03-07 | 2022-04-20 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-03-07 | 2022-04-20 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-03-07 | 2022-04-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-03-07 | 2022-04-20 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-03-07 | 2022-04-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-07 | 2022-04-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-07 | 2022-04-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-03-07 | 2022-04-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-03-07 | 2022-04-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-03-07 | 2022-04-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-03-07 | 2022-04-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-07 | 2022-04-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-03 | 2022-03-14 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-02-03 | 2022-03-14 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-02-03 | 2022-03-14 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-02-03 | 2022-03-14 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-02-03 | 2022-03-14 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-02-03 | 2022-03-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-03 | 2022-03-14 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-02-03 | 2022-03-14 | N |
| 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. | Health | 2022-02-03 | 2022-03-14 | N |
| 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. | Health | 2022-02-03 | 2022-03-14 | N |
| Provide or obtain dental services for each resident. | Health | 2022-02-03 | 2022-03-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-02-03 | 2022-03-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-03 | 2022-03-14 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-12-21 | 2022-01-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-02 | 2021-12-03 | Y |
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