Sancta Maria Nursing Facility: Weight Gain Alert Missed - MA
The resident, identified in inspection records only as Resident #328, had a care plan and a standing physician order that both said the same thing: if weight climbs three pounds or more in two days, or five pounds or more in a week, notify the doctor or nurse practitioner immediately. The order had been in place since February 17. The care plan had been in place since February 14.
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Weight logs reviewed by inspectors told the story in numbers. On February 20, the resident weighed 172.4 pounds. The next day, 170.8. Then, on February 24, the scale read 167.6. The following day, February 25, it read 170.2. But those figures only capture part of what happened. Nursing progress notes from February 16 through February 24 contained no record of the doctor being notified about a 12.6-pound gain in a single day, and no record that a doctor or nurse practitioner had assessed the resident's weight at all during that stretch.
For a patient with congestive heart failure, sudden weight gain is not a number to log and move on from. It is one of the primary warning signs that fluid is accumulating in the body faster than the heart can manage. The care plan existed precisely because the stakes are that direct.
By February 25, the resident had developed 1-plus pitting edema in both feet. A nurse pressed a finger against the skin and left an indentation. That finding made it into a weight change note that day. The doctor had still not been called.
Charge Nurse #2, interviewed by inspectors that afternoon, did not dispute what had happened. The resident gained over ten pounds the previous week over many days, the nurse said, and the doctor should have been notified before that day. The nurse acknowledged the doctor had not been.
The Director of Nursing, interviewed the following day, said he expects nursing staff to follow physician orders, notify the doctor of weight changes, and document the notification in a progress note. He said it as a matter of expectation, not as a description of what occurred.
What occurred was that a resident with a documented heart condition, under explicit orders to be monitored for exactly this kind of change, went without physician contact for the better part of a week while her body retained fluid and her feet swelled.
Inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. That classification reflects the regulatory framework inspectors work within, not a medical assessment of what fluid accumulation means for someone whose heart is already struggling to keep up.
Sancta Maria Nursing Facility sits on Concord Avenue in Cambridge and is certified by Medicare and Medicaid. The inspection was conducted on February 26, 2025.
The charge nurse's words at the end of that Tuesday afternoon were precise in a way that formal inspection language rarely is. The doctor should have been notified before today. The doctor was not notified before today. Both of those things were true at the same time, and the resident's feet showed the result.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sancta Maria Nursing Facility from 2025-02-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 14, 2026 · Our methodology
Sancta Maria Nursing Facility in CAMBRIDGE, MA was cited for violations during a health inspection on February 26, 2025.
The order had been in place since February 17.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.