Sancta Maria Nursing Facility

Review of Resident #92's Minimum Data Set (MDS) assessment, dated 12/18/24, indicated that he/she scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she as having intact cognition.

Review of Resident #92's care plans indicated a care plan with the focus: Resident #92 is at risk for falls D/T (due to) unsteady gait, decreased balance, generalized weakness and impaired mobility due repeated falls, legally blind, poor safety awareness, use of antidepressant and antianxiety medications, diuretic medication, opioid use for pain, confusion, oxygen use, incontinence, date initiated 1/2/2024.

Review of the following fall risk evaluations indicated Resident #92 was at risk for falls: 9/23/24 comprehensive, 10/8/24 quarterly,10/8/24 other, 11/7/24 other, 12/3/24 quarterly,12/4/24 admission,12/16/24 other,12/18/24 quarterly, 12/22/24 other, 12/24/24 other, 2/5/25 quarterly, 2/6/25 other, 2/19/25 other, and 2/21/25.

Review of the incident reports provided to the surveyor by the Director of Nursing indicated Resident #92 sustained 12 falls between 9/6/2024 through 2/21/2025. Of the 12 falls, 10 were not witnessed.

Review of the 10 not witnessed fall incident reports, indicated 6 did not include 72-hour neurological assessment low sheets.

Review of the incident reports indicated the following:

225573

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 225573 B.

Wing 02/26/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sancta Maria Nursing Facility 799 Concord Avenue Cambridge, MA 02138