The Center at Advocate
111 Orient Avenue, East Boston, MA 02128 · Suffolk County · 190 certified beds · avg 158 residents/day · certified since Jul 1, 1990
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Jun 10, 2024 · F-0740
The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety.
Why it matters: A resident's untreated mental health needs can worsen and take a toll on their physical health too.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jun 27, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Jun 10, 2024 · F-0742
The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD).
Why it matters: Residents with mental health needs who go untreated can suffer worsening symptoms, distress, and isolation.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jun 27, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Jun 10, 2024 · F-0835
The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents.
Why it matters: Poor administration often shows up as understaffing, supply shortages, and care problems across the whole facility.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jun 27, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 23, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 21, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 10, 2024 · F-0688
The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Why it matters: Without this care, residents can develop stiff, contracted joints and lose the ability to move on their own.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 27, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 10, 2024 · F-0745
The facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life.
Why it matters: Without social services support, residents can struggle emotionally and miss out on help they're entitled to.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 27, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 26, 2023 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 22, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (66)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Dec 19, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. · from a complaint |
| Dec 19, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Dec 19, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Jun 5, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Jun 5, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jun 5, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Jun 5, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jun 5, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jun 5, 2025 | D · Potential for harm, one-off | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. |
| Jun 5, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jun 5, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Apr 23, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Apr 23, 2025 | D · Potential for harm, one-off | The facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences. · from a complaint |
| Apr 23, 2025 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Apr 23, 2025 | D · Potential for harm, one-off | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. · from a complaint |
| Apr 23, 2025 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Apr 23, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Nov 4, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Jun 10, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. |
| Jun 10, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD). |
| Jun 10, 2024 | ▲ J · Immediate jeopardy, one-off | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. |
| Jun 10, 2024 | ▲ G · Actual harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Jun 10, 2024 | ▲ G · Actual harm, one-off | The facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. |
| Jun 10, 2024 | F · Potential for harm, facility-wide | The facility did not observe each nurse aide's job performance or provide regular training as required. |
| Jun 10, 2024 | F · Potential for harm, facility-wide | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. |
| Jun 10, 2024 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jun 10, 2024 | E · Potential for harm, repeated | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| Jun 10, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jun 10, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jun 10, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jun 10, 2024 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Jun 10, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
| Jun 10, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Jun 10, 2024 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Jun 10, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jun 10, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jun 10, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jun 10, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Jun 10, 2024 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Jun 10, 2024 | D · Potential for harm, one-off | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. |
| Jun 10, 2024 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Jun 10, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Jun 10, 2024 | D · Potential for harm, one-off | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
| Jun 10, 2024 | D · Potential for harm, one-off | The facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. |
| Jun 10, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Jun 10, 2024 | D · Potential for harm, one-off | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. |
| Apr 26, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Apr 26, 2023 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
| Apr 26, 2023 | E · Potential for harm, repeated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Apr 26, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Apr 26, 2023 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Apr 26, 2023 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Apr 26, 2023 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Apr 26, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Apr 26, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Apr 26, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Apr 26, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Apr 26, 2023 | D · Potential for harm, one-off | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. |
| Apr 26, 2023 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Apr 26, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Apr 26, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Apr 26, 2023 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Apr 26, 2023 | D · Potential for harm, one-off | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. |
| Apr 26, 2023 | D · Potential for harm, one-off | The facility did not make sure special medical diets — like low-sodium or diabetic diets — were properly ordered by the resident's doctor or managed by a qualified dietitian as state law allows. |
| Apr 26, 2023 | B · Minimal risk, repeated | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Apr 26, 2023 | B · Minimal risk, repeated | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (28 → 8).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 20 | 1 | G ▲ |
| 2024 | 29 | 5 | J ▲ |
| 2025 | 17 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $69,000.
| Date | Type | Amount / length |
|---|---|---|
| Apr 23, 2025 | Fine | $15,316 |
| Jun 10, 2024 | Fine | $53,684 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Massachusetts avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.25 | 3.89 | 3.95 | bottom 17% in Massachusetts; bottom 24% in the U.S. |
| Registered Nurse hours | 0.38 | 0.65 | 0.69 | bottom 11% in Massachusetts; bottom 19% in the U.S. |
| Weekend total nurse staffing | 2.92 | 3.51 | 3.50 | bottom 16% in Massachusetts; bottom 27% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.28 | 0.46 | 0.48 | bottom 23% in Massachusetts; bottom 29% in the U.S. |
| Total nursing staff turnover (%) | 41.5 | 38.2 | 45.8 | bottom 36% in Massachusetts; top 40% in the U.S. |
| RN turnover (%) | 44.4 | 42.6 | 42.9 | bottom 45% in Massachusetts; bottom 45% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.28, RN 0.38, weekend 2.95. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: 3/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Advocate Opco Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 03/01/2025 |
| Apfelbaum, Naftali | Individual | Indirect Ownership Interest | NOT APPLICABLE | 03/01/2025 |
| Brass Ma Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 03/01/2025 |
| BSD Elm Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 03/01/2025 |
| Gelbwachs, Gittell | Individual | Indirect Ownership Interest | NOT APPLICABLE | 03/01/2025 |
| Ma 1 Holdco Opco LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 03/01/2025 |
| Ofg Magenta LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 03/01/2025 |
| Rabinowitz, Devorah | Individual | Indirect Ownership Interest | NOT APPLICABLE | 03/01/2025 |
| Salzman, David | Individual | Indirect Ownership Interest | NOT APPLICABLE | 03/01/2025 |
| Support Opco Descendants Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 03/01/2025 |
| Tja HC Holdings LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 03/01/2025 |
| 111 Orient Propco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2025 |
| Apfelbaum, Naftali | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2025 |
| Apfelbaum, Naftali | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2025 |
| Asma 1 LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2025 |
| BH 1 Ma LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2025 |
| Care Network Services LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 03/01/2025 |
| Care Network Services LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2025 |
| Gelbwachs, Gittell | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2025 |
| Likhi, Rishi | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What mental health services do you provide on-site, and who delivers them?"
- "What mental health services do you offer on-site, and how do you care for residents with depression, anxiety, or a history of trauma?"
- "What were the findings behind this administration citation, and what has leadership changed since?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
- "Who provides social services here, and how would they support my family member's emotional and social needs?"
- "What choices do residents have over their daily schedule, like meal times, bathing, and activities?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Highland Park Rehabilitation and Healthcare Center | 1.0 mi | Chelsea, MA | ★☆☆☆☆ | 1/5 | |
| Katzman Family Center for Living | 1.4 mi | Chelsea, MA | ★★★★★ | 5/5 | |
| The Massachusetts Veterans Home at Chelsea | 1.5 mi | Chelsea, MA | ★★★★☆ | 4/5 | |
| Lighthouse Rehabilitation and Healthcare Center | 1.8 mi | Revere, MA | ★★☆☆☆ | 2/5 | |
| Leonard Florence Center for Living | 2.0 mi | Chelsea, MA | ★★★★★ | 5/5 | |
| Rehabilitation & Nursing Center at Everett (the) | 2.3 mi | Everett, MA | ★★★☆☆ | 4/5 | |
| North End Rehabilitation and Healthcare Center | 3.1 mi | Boston, MA | ★★☆☆☆ | 2/5 | |
| Dexter House Healthcare | 3.6 mi | Malden, MA | ★★★☆☆ | 3/5 | |
| Saugus Center | 4.2 mi | Saugus, MA | ★☆☆☆☆ | 1/5 | SFF |
| Chestnut Woods Rehabilitation and Healthcare Ctr | 4.7 mi | Saugus, MA | ★★★★☆ | 3/5 | |
| Regalcare at Glen Ridge | 5.0 mi | Medford, MA | ★☆☆☆☆ | 1/5 | |
| Jesmond Skilled Nursing & Rehabilitation Center | 5.0 mi | Nahant, MA | ★★★☆☆ | 3/5 |
Compare this facility with the 3 closest →
All facilities in East Boston →
Facility data as of CMS processing date 2026-08-01. CCN 225413.