Sancta Maria Nursing Facility
Sancta Maria Nursing Facility in CAMBRIDGE, MA — inspection on February 26, 2025.
Found 13 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Resident #328's Congestive Heart Failure (CHF) care plan, dated 2/14/25, indicated Daily weight, record in log, if weight 3# or greater in 2 days or 5# or greater in one week, notify MD/NP (Medical Doctor/Nurse Practitioner).
Review of Resident #328's physician order, dated 2/17/25, indicated CHF: Daily weight.
Notify MD/NP if weight is > or equal to 3 lbs. (pounds) in 2 days or 5 lbs./week.
Review of Resident #328's nursing progress notes 2/16/25 to 2/24/25 failed to indicate that the MD was notified with the 12.6 lbs. weight gain in one day or any weight gain thereafter.
Review of Resident #328's MD/NP assessments dated from 2/16/25 to 2/24/25 failed to indicate that the MD or NP assessed the Resident's weight gain.
Review of Resident #328's nursing weight change note, dated 2/25/25, indicated both feet noted with 1+ pitting edema.
During an interview on 2/25/25 at 2:15 P.M., Charge Nurse #2 said the Resident gained over 10 lbs. last week over many days and the MD should have been notified before today but was not.
During an interview on 2/26/25 at 2:20 P.M., the Director of Nursing (DON) said he expects nursing to follow the doctors order and to notify the MD of Resident #328's weight gain and write a progress note.
225573 02/26/2025
Sancta Maria Nursing Facility 799 Concord Avenue Cambridge, MA 02138
Review of Resident #27's physician orders indicated the following orders: -Aripiprazole (An antipsychotic medication) oral tablet 5 MG (milligrams), initiated on 2/18/25. -Olanzapine (An antipsychotic medication) oral tablet 2.5 MG (milligrams), initiated on 2/21/25.
Review of Resident #27's interdisciplinary care plans failed to indicate a care plan was developed for the Resident's antipsychotic medication use.
During an interview on 2/25/25 at 12:22 P.M., Charge Nurse #1 said the Unit Manager is responsible for developing care plans and he was unsure if residents taking antipsychotics should have a care plan developed for this care area.
During an interview on 2/25/25 at 12:34 P.M., Unit Manager #2 said residents who are taking antipsychotic medications do not require a care plan to be developed for this care area.
During an interview on 2/25/25 at 12:50 P.M., the Director of Nursing said antipsychotic care plans should be developed for any resident who is taking an antipsychotic medication.
The Director of Nursing said this type of care plan would be separate from the general psychotropic medication care plan.
225573 02/26/2025
Sancta Maria Nursing Facility 799 Concord Avenue Cambridge, MA 02138
Review of Resident #48's medical record assessments and nursing progress notes failed to indicate
During an interview on 2/25/25 at 9:50 A.M., Nurse #4 said skin checks should be completed weekly and the nurse completing them should document the skin check under the assessment tab in the medical record.
During an interview on 2/25/25 at 9:53 A.M., the Director of Nurses (DON) said the weekly skin assessment should be completed under the assessment tab or write a progress note that a full body skin check was done by the nurse.
During an interview on 2/25/25 at 2:02 P.M., the Assistant Director of Nursing (ADON) reviewed Resident #48's medical record.
The ADON said there are no skin checks in the medical record since 4/29/24.
The ADON said even if it's marked as implemented on the treatment administration record, it's not considered completed unless there is a skin check assessment completed under the assessment tab.
During an interview on 2/25/25 at 2:17 P.M., the DON said Resident #48 should have had a skin check completed weekly but was not able to locate one in the Resident's medical record since April 2024.
The DON said there was a change in their medical record system, and they were missed.
225573 02/26/2025
Sancta Maria Nursing Facility 799 Concord Avenue Cambridge, MA 02138
During an interview on 2/26/25 at 9:11 A.M., Unit Manager #3 said the doctor gave the order for the abdominal pad for Resident #54 and said the Resident was being treated with an antifungal treatment to his/her hand.
Unit Manager #3 said the order for the abdominal pad should be followed and that staff are to report any changes in a resident's skin.
Review of the medical record failed to indicate how the discoloration area on Resident's left hand was monitored for wound development.
225573 02/26/2025
Sancta Maria Nursing Facility 799 Concord Avenue Cambridge, MA 02138
Review of Resident #428's treatment administration record, dated 2/22/25, 2/23/25, 2/24/25, and
- Wound Care - Cleanse Coccyx Stage 2 pressure wound with Vashe (a type of wound cleanser) or any antibacterial wound cleanser.
Pat dry, apply Adaptic, then Calcium Alginate and then cover with dry protective dressing, initiated 2/21/25.
During a follow-up interview on 2/26/25 at 9:37 A.M., Charge Nurse #1 said the coccyx wound treatment order was for a stage two pressure wound.
Charge Nurse #1 said during each wound dressing change he had completed the wound had not been a stage two pressure wound, but always a deep tissue injury with intact skin.
Charge Nurse #1 said he was not aware if calcium alginate or adaptic were appropriate treatments for intact skin or deep tissue injuries.
Charge Nurse #1 said this should have been clarified, but it's not his job.
Charge Nurse #1 said it was Unit Manager #2's job to clarify orders with the physician if they don't match during the weekly wound rounds.
During an interview on 2/26/25 at 9:42 A.M., Unit Manager #2 said on admission she reviewed Resident #428's hospital discharge paperwork for wound care orders.
Unit Manager #2 said the hospital discharge paperwork recommended triad paste, which they do not use in the facility, so she called the physician and asked for an alternative treatment.
Unit Manager #2 said she never visualized the wound herself, but since triad is usually for stage two pressure wounds, she told the physician Resident #428 had a stage two pressure wound on his/her coccyx.
Unit Manager #2 said the physician ordered adaptic and calcium alginate for a stage two pressure wound.
Unit Manager #2 said she would have expected Charge Nurse #1 to clarify the order when he first noted the wound status did not match the treatment order.
Review of Resident #428's hospital discharge paperwork and admission paperwork, both dated 2/20/25, failed to indicate Resident #428 had a stage two pressure wound.
The hospital discharge paperwork, dated 2/20/25, indicated sacral deep tissue injuries.
During an interview on 2/26/25 at 11:15 A.M., the Regional Nurse Consultant said adaptic and calcium alginate are not appropriate wound treatments for intact skin or deep tissue injury and Charge Nurse #1 should have stopped the dressing change with the surveyor and clarified the wound treatment orders.
During an interview on 2/26/25 at 1:50 P.M., the Director of Nursing (DON) said adaptic and calcium alginate are not appropriate wound treatments for intact skin or deep tissue injury and Charge Nurse #1 should have clarified the physician order when he first noted the wound status did not match the treatment order.
Refer to F-F726.
225573 02/26/2025
Sancta Maria Nursing Facility 799 Concord Avenue Cambridge, MA 02138
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.
225573 02/26/2025
Sancta Maria Nursing Facility 799 Concord Avenue Cambridge, MA 02138
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.
225573 02/26/2025
Sancta Maria Nursing Facility 799 Concord Avenue Cambridge, MA 02138
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.
225573 02/26/2025
Sancta Maria Nursing Facility 799 Concord Avenue Cambridge, MA 02138
Review of the Brief Interview for Mental Status (BIMS) exam dated 2/15/25, indicated Resident #27 scored a 4 out of 15, which indicated he/she had severe cognitive impairment.
Review of Resident #27's physician orders indicated the following: -The Resident was admitted to the facility with an existing order for Aripprazole (An antipsychotic medication) oral tablet 5 MG (milligrams). -Three days after admission, the Resident was ordered to begin being administered Olanzapine (An antipsychotic medication) oral tablet 2.5 MG (milligrams), initiated on 2/21/25.
Review of Resident #27's list of medical diagnoses failed to include a diagnosis indicating the use of an antipsychotic.
Review of Resident #27's medical chart failed to indicate any nursing notes regarding exhibited behaviors of psychosis or agitation from the Resident.
During an interview on 2/25/25 at 12:22 P.M., Charge Nurse #1 said residents who are prescribed antipsychotic medications require a diagnosis indicating the warranted use of this type of medication.
During an interview on 2/25/25 at 12:34 P.M., Unit Manager #2 said there must be a justification for the use of antipsychotic medications and a diagnosis must be in place for the use of these medications.
Unit Manager #2 said Resident #27 was admitted to the facility with a prescription for Aripprazole and was then started on Olanzapine because his/her spouse thought it would be beneficial.
Unit Manager #2 then reviewed Resident #27's diagnoses with the surveyor and said the Resident did not have a current diagnosis listed to justify the use of these medications.
During an interview on 2/25/25 at 12:50 P.M., the Director of Nursing said an appropriate diagnosis is required for the use pf antipsychotic medications.
225573 02/26/2025
Sancta Maria Nursing Facility 799 Concord Avenue Cambridge, MA 02138
medication cart drawer and place the pack on top of the cart.
Nurse #1 then told the surveyor she
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.
225573 02/26/2025
Sancta Maria Nursing Facility 799 Concord Avenue Cambridge, MA 02138
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.
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.
225573 02/26/2025
Sancta Maria Nursing Facility 799 Concord Avenue Cambridge, MA 02138
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
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.