Sancta Maria Nursing Facility

F-F726. Residents Affected - Few 52138

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 31 225573 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm 36431

Residents Affected - Few Based on record review and interview the facility failed to ensure for 1 Resident (#92) out of a total sample of 27 residents, that 72-hour neurological checks were conducted after Resident #92 sustained unwitnessed falls.

Findings include:

Review of the facilities policy titled, Falls Management, last updated October 2023, indicated the facility will utilize resident/patient related information made available upon admission and ongoing to determine resident/patient at risk for fall status. Procedure: A fall risk evaluation will be conducted by the nurse on duty/supervisor on any resident/patient sustaining a fall with or without injury. Once the resident/patient is clinically evaluated as being stable, vital signs, neurological signs, range of motion, and evaluation of cognitive status will be documented. Neurological checks, to be documented on the neurological flow sheet for 72 hours in the following circumstances, resident/patient states that he/she hit head, physical evidence resident hit head, and unwitnessed fall.

Resident #92 was admitted to the facility April 2022 and has diagnoses that include but are not limited to legal blindness, repeated falls, cataracts, acute on chronic systolic heart failure and cognitive communication deficit.

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:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 31 225573 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0689 -Fall date 9/8/24, at 5:31 P.M., Fall was not witnessed. Fall occurred bedside. An initial Neurological focused evaluation was conducted. Review of the incident report failed to indicate a 72-hour neuro flow sheet was Level of Harm - Minimal harm or completed. potential for actual harm -Fall date 10/6/24, 06:00 (6:00 A.M.) fall was not witnessed. Fall occurred in Resident's room. Resident was Residents Affected - Few attempting to self-toilet at the time of the fall. Further review of the incident report failed to indicate 72-hour neurological checks were conducted.

-Fall 11/7/24 at 5:45 P.M., Fall was not witnessed. Fall occurred in the bathroom. An initial focused neurological focused evaluation was completed, no further 72-hour neurological flow sheet was completed.

-Fall 11/13/25, at 7:36 P.M., fall was not witnessed. Fall occurred in the Resident's room. A neurological focused evaluation was conducted. Further review failed to indicate a 72-hour neurological flow sheet was completed.

-Fall date 12/22/24, at 6:30 A.M., Fall not witnessed. Fall occurred in the bathroom. Initial neuro check conducted; no further 72-hour neurological flow sheet was completed.

-Fall 2/19/25, 12:00 P.M., Fall was not witnessed. Fall occurred in Resident's room. Further review failed to indicate a 72-hour neurological check was completed.

During an interview on 2/26/25 at 11:20 A.M., Unit Manager #3 said Resident #92 is at high risk for falls and has had multiple falls. Unit Manager #3 said all falls Resident #92 has sustained are reviewed and the care plan revised. Unit Manager #3 said all falls that are not witnessed require 72-hour neuro checks that are documented on paper neuro flow sheets. Unit Manager said once completed the neurological flow sheets are given to the Director of Nursing as part of the incident report.

During an interview on 2/26/25 at 11:44 A.M. The Director of Nursing said neuro checks were required on falls with head strikes or falls that are not witnessed. The DON said the Neurological checks are completed

on paper and that the nursing staff and Unit managers are responsible to ensure the neuro checks are conducted. The DON said he was not entirely sure where the missing neuro checks were for Resident #92.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 31 225573 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0726 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. Level of Harm - Minimal harm or potential for actual harm 48990

Residents Affected - Some Based on interviews, record review, staff education review, and Facility Assessment review, the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skill sets necessary to provide the level and types of care and services needed as outlined in the Facility Assessment. Specifically,

the facility failed to ensure licensed nursing staff were trained and demonstrated competency related to wound care.

Findings include:

According to the Board of Registration in Nursing, 244 CMR 9.00: Standards of Conduct, a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice.

Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that

an individual needs to perform work roles or occupational functions successfully.

Review of the comprehensive Facility Assessment Tool, updated and reviewed August 2024, included but was not limited to the following:

- Services and Care We Offer Based on our Residents' Needs: Skin integrity: Pressure injury prevention and care, skin care, wound care (surgical, other skin wounds.)

- Staff training/education and competencies: Ongoing staff training and education is provided to all departments within the facility specific to each discipline. We also provide annual training along with annual competencies that are required for all departments in the facility according to DPH regulations.

- Annual Competencies for Nurses (subject to change): Clean Dressing Change.

Review of the summarized Facility Assessment Tool, updated and reviewed February 2025, included but was not limited to the following:

- Services and Care We Offer Based on our Residents' Needs: Skin integrity: Pressure injury prevention and care, skin care, wound care (surgical, other skin wounds). Weekly wound rounds with physician.

- Staff training/education and competencies: Additional full day staff orientation, depending on position, for specific skill and competencies. Annual Education Fair and Core Competency evaluations.

- Competencies: Specialized Care - wound care/dressings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 31 225573 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0726 During an interview on 2/26/25 at 1:11 P.M., the Administrator said both the above referenced Facility Assessment Tools are current, but one is more comprehensive and the other is a summary. The Level of Harm - Minimal harm or Administrator said both should be followed. potential for actual harm Throughout the recertification survey (2/24/25 through 2/26/25) the surveyors identified multiple concerns Residents Affected - Some regarding wound care including:

- failure to implement wound treatments following physician's orders.

- failure to obtain new treatment orders for a pressure wound when the wound status changed and current treatment order was no longer appropriate.

- failure to complete weekly skin checks.

The surveyor reviewed staff education files for wound competencies for three licensed nurses who provided wound care during the recertification survey.

- 0 out of 3 nurses had evidence of wound care competencies completed since hire.

During an interview on 2/26/25 at 1:21 P.M., the Assistant Director of Nursing (ADON) said she was responsible for staff competencies and training. The ADON said she was unaware wound or wound dressing competencies were required annually or upon hire. The ADON said if wound or wound dressing competencies are indicated as required on the Facility Assessment, then they should have been completed.

The ADON said she has not done any wound related competencies that include return demonstration since

she started the position in September 2024. The ADON said she was unable to locate any wound competencies for the three licensed nurse files requested since they were hired.

During an interview on 2/26/25 at 1:50 P.M., the Director of Nursing (DON) said wound care competencies should completed as indicated in the Facility Assessment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 31 225573 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm 15016

Residents Affected - Few Based on record review and interview, the facility failed to ensure the pharmacist completed a Monthly Medication Review (MMR) for one Resident (#8), out of 27 sampled residents.

Findings include:

Resident #8 was admitted to the facility in November 2024, and had diagnoses that included bipolar disorder, schizophrenia and diabetes type II.

Review of Resident #8's physician orders, dated February 2025, indicated they included, but were not limited to, the following medications:

- Trazodone (antidepressant) 150 milligrams (mg) one tablet one time per day.

- Zoloft (antidepressant) 100 mg two tablets one time per day.

- Risperidone 0.5 mg (antipsychotic) one tablet two times per day.

- Metformin (antidiabetic medication) 500 mg one tablet two times per day.

Review of Resident #8's MMRs, performed by the pharmacist, from November 2024 through January 2025, indicated an MMR was not completed for December 2024.

During an interview on 2/25/25 at 8:22 A.M., the Director of Nursing (DON) said Resident #8's MMRs, located in the electronic and paper records, did not include a review for December 2024. The DON said he would try to locate the missing MMR. As of the last day of survey, the DON had not provided a copy of the December MMR.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 31 225573 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0761 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 Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 43846 Residents Affected - Some Based on observations, interviews and policy review, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically,

1. The facility failed to ensure treatment carts and medication carts were locked while a nurse was not present on the fourth floor.

2. The facility failed to ensure nursing staff secured medications in the medication cart prior to leaving the cart unattended on the fourth and fifth floor units.

Findings include:

Review of the facility policy titled Medication Administration and Charting Policy, dated as revised November 2024, indicated Medication carts must always remain locked, unless the nurse who is administering the medication is in direct control of the medication cart. If the medication cart is left unattended it must be locked.

Review of the facility policy titled Mediation Storage, not dated, indicated it is the policy of the facility to store all medications in a safe and orderly manner. Unlocked medication carts are not left unattended by the nurse with carts keys.

1. On 2/24/25 from 7:37 A.M. to 7:46 A.M., the surveyor observed the treatment cart unlocked and unsupervised on the 4th floor unit. The surveyor observed a resident and staff members walking by the unlocked treatment cart multiple times.

On 2/24/25 at 8:12 A.M., the surveyor observed a medication unlocked and unsupervised on the 4th floor unit. No staff were present.

During an interview on 2/26/25 at 9:06 A.M., Unit Manager #2 said she expects nursing staff to lock the medication carts and treatment carts when the nurse is not present at the carts.

On 2/26/25 at 9:30 A.M., the surveyor observed a 4th floor treatment cart unlocked in the hallway. The nurse was not within sight line of the treatment cart. The surveyor observed multiple prescription topical medications within this treatment cart.

During an interview on 2/26/25 at 9:34 A.M., Unit Manager #2 came within view of the treatment cart and locked it. Unit Manager #2 said the treatment cart should have been locked when not within the nurses' view.

2. On 2/25/25 at 12:00 P.M., the surveyor observed a Trelegy inhaler on top of a medication cart on the 4th floor. The nurse was not present at the cart or in the hallway.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 31 225573 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0761 During an interview on 2/26/25 at 9:06 A.M., Unit Manager #2 said medications should never be left unattended on top of the medication cart. Level of Harm - Minimal harm or potential for actual harm 15016

Residents Affected - Some On 2/25/25 at 9:27 A.M., during the medication pass on the fifth floor unit, the surveyor observed Nurse #1 remove a blister pack of Escitalopram 5 milligram tablets (antidepressant) from the medication cart drawer and place the pack on top of the cart. Nurse #1 then told the surveyor she needed to leave and get additional medications from the medication room. Nurse #1 then locked the medication cart and walked down the hallway and around a corner.

The surveyor observed there were 13 tablets of Escitalopram in the blister pack. No other nursing staff were within eyesight of the cart.

On 2/25/25 at approximately 9:31 A.M., Nurse #1 returned to the medication cart. Nurse #1 then unlocked

the cart and returned the blister pack of escitalopram to the cart drawer and then locked the cart. Nurse #1 said she should not have left the Escitalopram unsecured and unattended on top of the medication cart while

she was getting additional medications from the medication storage room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 31 225573 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Level of Harm - Minimal harm or 48990 potential for actual harm Based on observations, interviews and record review, the facility failed to provide adaptive equipment for one Residents Affected - Few Resident (#37) out of a total sample of 27 residents. Specifically, the facility failed to ensure Resident #37 was provided with a two handled cup for use during his/her drinks and liquids to maximize intake.

Findings include:

Review of the facility policy titled 'Adaptive Equipment Policy', undated, indicated:

- As a part of our ongoing effort to make our residents' health the top priority, the facility will comply with the below guideline to assure the oversight of any adaptive equipment administered to a resident in the center.

This will ensure that once issued all equipment in place, is maintained to quality standards, and is continuously appropriate and available to the resident.

- Upon identifying a specialty therapy equipment piece should be issued:

a. While the resident is on services: The treating therapist shall provide education to the resident and any staff members and caregivers who may be involved in the oversight of the piece of equipment.

ii. It is the responsibility of the therapy department to care plan and/or to assure nursing is aware of any care plan to be written for the use of the adaptive feeding equipment

iii. It is the responsibility of the therapy department to assure the center specific communication process to

the dietary department occurs if it involves the equipment to be provided at meal times. (i.e., completing a pink communication slip and providing this to the dietary department).

b. Upon discharging the resident from services:

i. The rehab department must ensure therapy to nursing communication has occurred to include any language to be added to the care plan.

Resident #37 was admitted to the facility in June 2024 with diagnoses including hemiparesis (one-sided muscle weakness) following a stroke.

Review of the most recent Minimum Data Set (MDS) assessment, dated 12/18/24, indicated Resident #37 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. This MDS also indicated Resident #37 required set up and clean up assistance with eating.

Review of Resident #37's occupational therapy progress note, dated 2/3/25, indicated she was providing therapy to maximize performance with self-feeding. The note also indicated:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 31 225573 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0810 - Pt (patient) was able to self-feed with built up handles MI (meaning minimum assistance) from table to mouth with 100% accuracy. Pt noted preference for two handled cup. Therapist noted 100% accuracy with Level of Harm - Minimal harm or two handle [sic] cup. Therapit [sic] ordered two handle cup with all meals. potential for actual harm

Review of Resident #37's physician telephone order, dated 2/3/25, indicated: Residents Affected - Few - Two handled cup with drinks at all meals.

Review of a dietary communication slip for Resident #37, dated 2/3/25, indicated:

- Two handled cup with drinks at all meals.

Review of Resident #37's active physician's orders and care plan on 2/25/25 at 8:30 A.M. failed to indicate two handled cups should be provided.

On 2/24/25 at 8:55 A.M., the surveyor observed Resident #37 eating breakfast. The meal slip on the tray indicated apple juice in a two handled cup should be on the breakfast tray. There was a carton of apple juice with a straw on the tray, which was not in a two handled cup. There was no two handle cup available on meal tray.

On 2/24/25 at 12:25 P.M., the surveyor observed Resident #37 eating lunch. The meal slip on the tray indicated chicken soup in a two handled cup should be on the lunch tray. There was a bowl of chicken soup

on the tray, which did not have any handles. There was no two handle cup available on meal tray. Resident #37 said it takes him/her a lot longer to drink the soup because the cup he/she likes with the handle hasn't been given to him/her in a while. Resident #37 said he/she likes when the two handled cups come because it's a lot easier to drink liquids. Resident #37 said his/her soup was now cold because it took him/her so long to eat it and requested the surveyor ask staff to heat up the soup.

On 2/25/25 at 8:14 A.M., the surveyor observed Resident #37 eating breakfast. The meal slip on the tray indicated orange juice should be on the tray, without any instructions for the orange juice to be in a two handled cup. There was a carton of orange juice with a straw on the tray, which was not in a two handled cup. There was no two handle cup available on meal tray. Resident #37 said he/she wished it was in a cup with two handles because he/she was having trouble drinking it.

During an interview on 2/25/25 at 2:36 P.M., the Director of Rehab (DOR) and the Food Service Director (FSD) said occupational therapy recommended a two handled cup with drinks for all meals on 2/3/25 and showed the surveyor the dietary communication slip indicating this was communicated to the kitchen. The DOR said therapy issued a two handled cup to Resident #37 which was being stored in the Resident's room.

The DOR said staff on the floor was supposed to make sure it was provided to the Resident for all drinks and liquids and that the staff was supposed to clean it between uses. The DOR said this plan had been in place until an order they had placed for a larger quantity of two handled cups to be available in the kitchen. The DOR said the larger quantity order had been delivered and given to the kitchen today (2/25/25).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 31 225573 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0810 During an interview on 2/26/26 at 8:54 A.M., Certified Nurse Assistant (CNA) #2 said the nurses check the meal slip to ensure everything and adaptive eating equipment is on the tray before it is delivered. CNA #2 Level of Harm - Minimal harm or said she was unaware Resident #37 required a two handled cup. CNA #2 said Resident #37 had a two potential for actual harm handled cup in his/her room, but they do not transfer any drinks or soups into it, and he/she has not been using it. Residents Affected - Few

During an interview on at 2/26/25 at 8:56 A.M., Unit Manager #3 said nurses are responsible to check the meal slip to ensure everything and adaptive eating equipment, including two handled cups, are on the tray

before it is delivered. Unit Manager #3 said if the two handled cups were indicated on the meal slip and were not available, the nurse should have called the kitchen to obtain the two handled cup or clarified the need for them with the therapy department. Unit Manager #3 said she was unaware Resident #37 had a two handled cup in his/her room, but that it shouldn't be stored there because they were not able to sanitize it on the unit. Unit Manager #3 went to Resident #37's room and confirmed there was a two handled cup being stored in his/her room. Unit Manager #3 located Resident #37's physician telephone order, dated 2/3/25, indicating two handled cup with drinks at all meals and said the physician telephone order had not been transcribed into the active physician's orders but should have.

During an interview on 2/26/25 at 10:46 A.M., the Director of Nursing (DON) said nurses are responsible to check the meal slip to ensure everything and adaptive eating equipment, including two handled cups, are on

the tray before it is delivered. The DON said if the two handled cups were indicated on the meal slip and were not available, the nurse should have called the kitchen to obtain the two handled cup or clarified the need for them with the therapy department. The DON said staff should have ensured the two handled cup, which was stored in his/her room, was provided to Resident #37.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 31 225573 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41456

Residents Affected - Some Based on observations, record reviews and interviews, the facility failed to maintain accurate medical records for two Residents (#89 and #30) out of a total sample of 27 residents.

Findings include:

1a. Resident #89 was admitted to the facility in November 2021 with diagnoses including epilepsy.

Review of Resident #89's most recent Minimum Data Set, dated dated dated [DATE REDACTED] indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 7 out of a possible 15 which indicated the Resident had severe cognitive impairment. The MDS also indicated Resident #89 is dependent on staff for all functional daily tasks.

On 2/24/25 at 8:50 A.M., and 4:45 P.M., Resident #89 was observed lying in bed with both side rails elevated without padding on either side rail.

On 2/25/25 at 07:14 A.M., and 10:04 A.M., Resident #89 was observed lying in bed with both side rails elevated without padding on either side rail.

Review of Resident #89's physician orders indicated the following:

-Seizure Precautions: Maintain Padded Top Side rails on Bed at all times for injury protection due to Seizures, initiated 4/18/24.

Review of the Treatment Administration Record for 2/24/25 and 2/25/25, indicated the nursing staff had marked the order as complete, indicating the padded siderails were present on Resident #89's bed.

During an interview on 2/26/25 at 10:55 A.M, the Director of Nursing said orders should not be marked as complete if not done

b. Resident #30 was admitted to the facility in September 2022 with diagnoses including Alzheimer's Disease.

Review of Resident #30's most recent Minimum Data Set (MDS) dated [DATE REDACTED], indicated the Resident was unable to complete the Brief Interview for Mental Status and the staff had assessed him/her to have severe cognitive impairment. The MDS also indicated Resident #30 is dependent on staff for all functional tasks.

On 2/24/25 at 8:55 A.M., Resident #30 was observed with a skin tear to his/her right lower arm. The Resident was not wearing any protective coverings to either arm.

On 2/24/25 at 12:35 P.M., Resident #30 was observed sitting in the dining room without any protective coverings to either arm.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 31 225573 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0842 Review of Resident #30's physician orders indicated the following order:

Level of Harm - Minimal harm or -Every shift -Geri Gloves (a skin protective garment) to both arms, initiated on 9/25/24. potential for actual harm

Review of the Treatment Administration Record (TAR) indicated the nursing staff had marked the order as Residents Affected - Some complete on 2/24/25, indicating Resident #30 had worn the geri-gloves.

During an interview on 10:32 A.M., Unit Manager #1 said Resident #30 has fragile skin and has an order for geri-gloves for this reason. Unit Manager #1 said Resident #30 often refuses the geri-gloves and if a refusal occurs it would be documented on the TAR. Unit Manager #1 said all orders should be followed as written and not marked as complete if not done.

During an interview on 2/26/25 at 10:55 A.M, the Director of Nursing said orders should not be marked as complete if not done.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 31 225573