Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sancta Maria Nursing Facility during CMS and state inspections, most recent first.
A resident at high fall risk with moderate cognitive impairment and a care plan requiring assistance for bed mobility fell out of bed during morning care when a CNA rolled the resident away from herself and then turned away to get a towel. The resident sustained a head strike and a left knee laceration that required ED transfer and sutures. The DON and Unit Manager stated CNAs are expected to roll residents toward themselves for safety.
Failure to submit PBJ staffing data. The facility did not electronically submit complete and accurate direct care staffing information to CMS for the reporting quarter. During record review, staff could not provide a PBJ reporting policy, and the PBJ Staffing Data Report showed no data submitted for the quarter with a triggered one-star staffing rating and several suppressed staffing metrics. The Administrator said he was responsible for the PBJ submission and that an error led to the missing report.
Failure to Maintain EBP During Resident Care: The facility did not consistently follow EBP for four residents who had orders or care plan directions for gown and glove use during high-contact care. Staff were observed providing direct care and wound care without gowns for residents with dialysis access, a vascular wound, a surgical wound, and an indwelling suprapubic catheter. The DON, nurses, and CNA acknowledged that gowns should have been worn during the observed care.
A resident with severe cognitive impairment had inconsistent Advance Directive documentation. The chart, care plan, MD note, and physician order all reflected DNR/DNI status, but the MOLST form only showed DNR with the DNI section left blank. Staff stated the MOLST should match the physician order and the resident’s wishes, but the record was not consistent.
A resident with Parkinson’s disease and recent acute delirium left AMA shortly after admission after the spouse was dissatisfied with aspects of the stay and requested medications be given before pharmacy delivery was available. Nursing notes show staff called the physician, but the resident left before the issue was resolved. The SW was not informed the resident had left and therefore did not notify the community PCP or elder-at-risk services as expected.
A resident with liver disease, kidney disease, and mild neurocognitive disorder had a physician order to offload the heels with multipodus boots every shift, and the care plan also directed heel offloading with the boots when in bed. Survey observations found the boots left off and placed on the bed or a chair while the resident was in bed and later in a wheelchair; the resident said staff had not put them on and denied refusing them. A CNA was unaware the resident was without the boots, and an RN stated CNAs were supposed to apply the boots and follow the MD order.
Two residents with dysphagia and aspiration-related diagnoses did not receive the meal supervision and eating assistance identified in their care plans and assessments. One resident, who was cognitively intact but pocketed food and coughed or choked during meals, was observed eating breakfast alone in the room on two occasions, and staff said they were not aware the resident needed supervision at every meal. The other resident, who was severely cognitively impaired and required substantial/maximal assistance with eating, also had a history of aspiration pneumonia and was identified by staff as needing supervision at all meals.
A resident with severe cognitive impairment, CKD, gout, failure to thrive, and falls had an arterial heel ulcer and sacral wound with documented pain and edema. Wound provider notes ordered lidocaine gel, LE elevation with gentle Ace wraps, offloading, and pre-medication before wound rounds, but these recommendations were not reflected in the physician orders. Surveyors observed the resident sitting with feet flat and not offloaded, and staff acknowledged the resident had pain during dressing changes and that the wound recommendations had not been entered timely.
A resident with respiratory failure, pneumonia, and severe cognitive impairment was observed multiple times receiving O2 via NC at 2.5 L/min even though the physician ordered 2 L/min to keep saturation above 90%. The resident’s oxygen controls were out of reach, and the chart did not show any order, note, or low O2 sat reading to justify the higher rate. The nurse, unit manager, and DON all stated oxygen should be given per the physician’s order.
Failure to identify PTSD triggers and trauma-informed interventions for a resident with PTSD, major depression, and a recent knee replacement. The resident was cognitively intact, but the care plan did not document triggers, mitigation interventions, or whether the resident refused to discuss PTSD or had no known triggers. Social services notes and the medical record also did not show that PTSD or potential triggers were assessed, and the resident reported that staff loud talking at night could trigger memories of childhood living situations.
Medications were left unsecured for two residents. A resident with glaucoma had Latanoprost eye drops on a windowsill, and another resident with asthma had an Advair inhaler on a bedside cabinet. Both residents were cognitively intact, but the record had no assessment, physician order, or care plan approval for self-administration, and an LPN stated that medications should not be at the bedside unless the resident has been approved to self-administer.
The facility failed to implement physician orders for eight residents, including not completing weekly skin assessments and not following orders for protective equipment. Residents at risk for pressure ulcers did not have documented skin checks, and others lacked required protective gear. Staff interviews confirmed the lack of compliance with orders.
The facility failed to ensure nursing staff were trained in wound care, as required by their Facility Assessment. Surveyors found issues such as not following physician's orders for wound treatments and not obtaining new orders when needed. Interviews revealed that the ADON was unaware of the need for wound care competencies, and no such competencies had been completed for the nurses involved.
The facility failed to secure treatment and medication carts, leaving them unlocked and unattended on multiple occasions. A Trelegy inhaler and a blister pack of Escitalopram were also left unsecured on medication carts. Staff confirmed that these actions were against facility policy.
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in care. A resident with epilepsy was observed without required padded side rails, despite records indicating compliance. Another resident with Alzheimer's was seen without protective coverings, contrary to physician orders. Staff acknowledged the discrepancies, emphasizing the importance of accurate documentation.
A resident with chronic conditions experienced a 12.6-pound weight gain in one day, but the facility failed to notify the physician as required by policy. Despite the care plan and physician orders indicating the need for notification with significant weight changes, there was no documentation of such communication. Staff interviews confirmed the oversight.
The facility failed to implement a skin integrity care plan for a resident with severe cognitive impairment, as the resident was observed without prescribed heel protectors. Additionally, the facility did not develop a care plan for the use of antipsychotic medications for another resident, despite the prescriptions. Staff interviews revealed a lack of awareness and misunderstanding regarding care plan requirements.
A resident with a left-hand contracture did not receive the prescribed care, as the facility failed to apply an abdominal pad to offload the palm from the fingers and did not monitor discoloration for wound development. Observations showed the resident without the pad, and staff interviews revealed a lack of awareness of the care plan. The Treatment Administration Record was signed off without documenting the discoloration's status, and weekly skin assessments were not completed as ordered.
A resident with a sacral deep tissue injury did not receive timely and appropriate pressure ulcer care. The facility delayed providing an air mattress and failed to set it correctly. Additionally, the prescribed wound care was not followed, as adaptic was not applied, and the wound was incorrectly treated as a stage two pressure wound instead of a deep tissue injury. The nursing staff did not clarify the treatment orders with the physician, leading to inappropriate care.
A resident at high risk for falls experienced multiple unwitnessed falls, but the facility failed to conduct the required 72-hour neurological checks for six of these incidents. Despite the facility's policy mandating such checks, documentation was missing, and the Director of Nursing was unsure of its whereabouts.
A facility failed to ensure a licensed pharmacist completed a Monthly Medication Review (MMR) for a resident with bipolar disorder, schizophrenia, and diabetes type II. The resident's MMR for December was missing, and the Director of Nursing confirmed it was not found in records, despite efforts to locate it.
A resident with hemiparesis was not provided with a two-handled cup for meals, despite a physician's order and occupational therapy recommendation. The resident struggled with self-feeding due to the lack of appropriate equipment, and staff were unaware of the requirement. The cup was improperly stored, and communication breakdowns led to the deficiency.
Unsafe Bed Mobility Assistance Led to Resident Fall and Laceration
Penalty
Summary
The facility failed to ensure a resident at high risk for falls and requiring staff assistance for bed mobility was kept safe during morning care. Resident #1 had an admission fall risk assessment showing high fall risk, a BIMS indicating moderate cognitive impairment, and an ADL care plan stating the resident required assistance from one to two staff members to turn and reposition in bed. The facility’s Falls Management policy defined a fall to include a resident rolling off a bed or mattress close to the floor. According to the facility’s report, post-fall investigation, and staff and resident interviews, CNA #1 raised the resident’s bed and assisted the resident to roll onto the resident’s right side, away from the CNA. CNA #1 then turned away to get a towel. While the CNA was turned away, the resident’s leg shifted off the side of the bed and the resident rolled out of bed onto the floor. The resident and CNA both stated that the resident had been rolled away from the CNA, and the Unit Manager and DON stated that CNAs were expected to roll a resident toward themselves, not away from themselves. The resident sustained a witnessed fall with a head strike during care and a left knee laceration. The resident was transferred to the hospital’s ED, where the laceration was measured at seven cm long and two cm deep and required a running lock suture to close. The DON’s investigation concluded that CNA #1 should not have rolled the resident away from herself and was unable to prevent the resident from rolling off the bed onto the floor.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for the entire FY Quarter 1 2026 reporting period, October 1 through December 31, in accordance with the CMS reporting schedule. During record review, the surveyor requested a policy regarding Payroll Based Journal (PBJ) reporting, but the facility was unable to provide one. Review of the PBJ Staffing Data Report for the quarter showed that the facility failed to submit data for the quarter, and the report also reflected triggered staffing metrics, including a one-star staffing rating, with several metrics suppressed for the facility and quarter. During an interview, the Administrator stated that he was responsible for submitting the PBJ reports and that an error occurred when he reported for the quarter, resulting in a missing report for the quarter.
Failure to Maintain Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, Enhanced Barrier Precautions (EBP) were not maintained for four residents who had orders or care plan interventions requiring gown and glove use during high-contact care activities. Resident #85 was admitted with diagnoses including kidney failure on dialysis, fall with major injury, and pneumonia. The resident was cognitively intact and required assistance with all activities of daily living. The physician ordered EBP because of increased risk of MDRO acquisition due to a dialysis catheter. On 3/25/26, a sign on the room door indicated EBP, and the surveyor and DON observed a CNA providing direct contact care without wearing a protective gown during the high-contact procedure. The DON stated that the resident was on EBP and staff should have been wearing gowns during high-contact care. Resident #40 was admitted with diagnoses including glaucoma, heart failure, and anxiety, was cognitively intact, and required assistance with all activities of daily living. The physician ordered EBP because of increased risk of MDRO acquisition due to a chronic left lower leg vascular wound. During observation, a CNA provided direct contact care without a protective gown, and the DON stated staff were to wear protective gowns whenever providing direct contact care to a resident on EBP. Resident #59 had diagnoses including a surgical wound to the right foot, sepsis, and congestive heart failure, was cognitively intact, and required assistance with activities of daily living. During wound treatment to the right foot, a nurse was observed without a protective gown, and both the nurse and another nurse acknowledged that a gown should have been worn. Resident #119 had diagnoses including muscle weakness and urinary retention, had moderate cognitive impairment, and had an indwelling suprapubic catheter. The resident’s care plan and physician orders required EBP with gown and glove use during high-contact care, but a staff member providing morning ADL care was observed wearing gloves only and no gown. The DON and Administrator stated that staff were expected to implement EBP as required.
Inconsistent Advance Directive Documentation
Penalty
Summary
Advance Directives were not accurately documented for one resident. Resident #14, who was admitted with diagnoses including cognitive communication deficit, major depressive disorder, repeated falls, and traumatic subdural hemorrhage, had a most recent MDS assessment showing a BIMS score of 6 out of 15, indicating severe cognitive impairment. The resident’s MDS, physician order, care plan, MD progress note, and social services note all documented DNR/DNI status, and social services noted that the MOLST read DNI, DNR. However, review of the resident’s MOLST form dated 2/14/22 showed DNR only, signed by the resident, with the DNI portion left blank. Facility staff acknowledged during interviews that the MOLST should match the physician order and that the resident’s MOLST did not match the documented DNR/DNI status in the medical record. The facility policy stated that MOLST orders must match facility code status orders and that discrepancies should be clarified immediately.
Failure to Notify Community Providers After AMA Departure
Penalty
Summary
The facility failed to ensure that appropriate information was communicated to the receiving health care institutions or providers for one resident. The resident was admitted in March 2026 with diagnoses including Parkinson’s disease, and the most recent MDS did not indicate a documented BIMS score. The resident signed his/her own MOLST on 3/11/26, indicating he/she was his/her own responsible party. Hospital discharge summary progress notes dated 3/11/26 stated that the resident had presented to the ED on 3/6/26 with acute delirium resulting in a motor vehicle collision. Nursing progress notes documented that the resident left AMA on the evening of admission after the spouse was unhappy with aspects of the stay and requested that all medications be given that evening. Staff informed the spouse that there was no in-house pharmacy and that medication delivery was pending, and a call was placed to the physician to address the issues, but the resident left before resolution. During interviews, the DON stated that when residents leave AMA, the SW should notify the resident’s primary care provider in the community and elder-at-risk services. The SW stated she was not aware the resident had left AMA, had not met the resident after admission, and expected to be informed so she could contact the community PCP and elder services because the resident wished to be discharged earlier than outlined in the plan of care.
Failure to Apply Ordered Multipodus Boots
Penalty
Summary
The facility failed to follow a physician’s order for Resident #118 by not ensuring multipodus boots were applied as ordered to offload the heels every shift. Resident #118 was admitted in January 2026 with diagnoses including liver disease, kidney disease, and mild neurocognitive disorder. The Minimum Data Set assessment indicated the resident was cognitively intact with a Brief Interview for Mental Status score of 13 out of 15 and required extensive assistance with lower body dressing. The care plan identified a focus on potential for pressure ulcer development related to decreased strength and endurance, diabetes, anemia, and HTN, with an intervention to offload both heels with multipodus boots when in bed. On 3/24/26, the surveyor observed Resident #118 in bed with the pressure relieving booties lying on the mattress at the end of the bed, and the resident stated staff had not put them on yet that day and that he/she was not able to put them on independently. Later that same day, the surveyor again observed the resident in bed with the booties on a chair across from the bed, and the resident stated staff never put the booties on that day and denied refusing them. CNA #1 stated she was not aware the resident did not have the booties on, and Nurse #2 stated the CNAs were supposed to put the multipodus booties on and physician orders were supposed to be followed. On 3/25/26, the surveyor observed the resident sitting in a wheelchair without multipodus boots on his/her feet.
Failure to Provide Meal Supervision for Residents with Dysphagia
Penalty
Summary
The facility failed to ensure that two residents who were unable to carry out activities of daily living received the necessary assistance during meals for safety with eating. Resident #24 was admitted with diagnoses including dysphagia, aspiration pneumonia, and blood clots in the left leg. The MDS indicated the resident was cognitively intact, pocketed food, and coughed or choked during meals. The care plan identified swallowing difficulty related to dysphagia and stated that the resident required assistance with eating, and the Functional Abilities and Goals document indicated supervision/touching assistance with eating. However, the surveyor observed the resident eating breakfast alone in the room on two separate mornings. Speech therapy notes showed treatment for dysphagia with a puree, thin diet, but did not indicate the level of assistance needed. CNA #2 and Nurse #2 stated they were not aware the resident was supposed to be supervised at every meal. Resident #125 was admitted with diagnoses including pneumonitis related to aspiration of food, dysphagia, and degenerative disease of the nervous system. The MDS indicated the resident was severely cognitively impaired, required substantial/maximal assistance with eating, and pocketed food and coughed or choked during meals. The care plan identified swallowing difficulty related to dysphagia and stated that the resident required assistance with eating. Progress notes documented a history of aspiration pneumonia. During interview, a family member said she was present daily for lunch and that the resident coughed occasionally while eating and was being trained to cough when needed during meals. CNA #2, CNA #1, and Nurse #2 each stated that the resident was supposed to be supervised at every meal.
Failure to Implement Wound Provider Orders for Painful Arterial Ulcers
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident with chronic kidney disease, gout, adult failure to thrive, falls, and severe cognitive impairment. The resident had an arterial ulcer and a sacral wound, and wound provider notes documented moderate bilateral lower extremity edema, moderate associated pain, and recommendations for 4% lidocaine gel to the wound daily and as needed for pain, lower extremity elevation with gentle compression therapy using gentle Ace wraps daily, and offloading. A later wound provider note also documented non-palpable pulses bilaterally and suggested pre-medicating the resident 30 minutes before wound rounds. The physician orders did not reflect any of these wound provider recommendations. Surveyors observed the resident sitting with feet flat on the ground and not offloaded. During interviews, the resident stated dressing changes were painful every day. Nursing staff stated the resident had pain during wound care, that scheduled pain medication had not yet been given, and that the wound provider recommendations were expected to be entered by staff but had not been timely implemented. The NP stated she expected nursing to enter the wound recommendations timely, including lidocaine, Ace wraps, and offloading, while the ADON stated staff were expected to put in all wound recommendations timely and acknowledged the lidocaine and Ace wrap orders were not in place.
Oxygen Administered Above Ordered Rate
Penalty
Summary
The facility failed to ensure that respiratory care was provided in accordance with the physician’s order for one resident with respiratory failure and pneumonia and a BIMS score of 7, indicating severe cognitive impairment. The resident’s active order directed oxygen at 2 liters per minute via nasal cannula to maintain oxygen saturation above 90%, but survey observations on multiple occasions found the resident receiving oxygen at 2.5 liters per minute. During these observations, the oxygen adjustment controls were out of the resident’s reach, and the resident was in bed receiving supplemental oxygen by nasal cannula. The resident’s record did not show any additional physician instruction authorizing the higher oxygen rate, and progress notes did not document a reason for increasing oxygen above the ordered rate. The resident’s vital signs summary also did not show oxygen saturation below 90%. During interviews, the nurse, unit manager, and DON all stated that oxygen should be administered per physician order and that any change in rate would require physician notification and documentation. The DON observed the oxygen setting and identified it as 2.5 liters per minute, which did not match the physician’s order for 2 liters per minute.
Failure to Identify PTSD Triggers and Trauma-Informed Interventions
Penalty
Summary
Provide care or services that was trauma informed and/or culturally competent was not ensured for Resident #25, who was admitted with diagnoses including PTSD, major depression, and status post left knee replacement. The resident was cognitively intact, scoring 14 out of 15 on the BIMS, and the record showed a diagnosis of PTSD. However, the current care plan did not identify triggers that might cause re-traumatization or interventions to help mitigate possible reactions to triggers, and it did not indicate whether the resident refused to discuss PTSD or stated that there were no known triggers. The social service progress notes did not show that Resident #25’s PTSD was discussed, and the medical record did not show an assessment for PTSD and potential triggers. During interview, the resident stated that no one had asked about the PTSD since admission and identified loud talking by staff at night as something that could bring back childhood living situations and make the resident sad. The DON stated in interview that the care plan should include triggers and interventions specific to the resident.
Medications Left Unsecured at Bedside
Penalty
Summary
The facility failed to ensure medications were secured in locked compartments for two residents. Resident #40, admitted with diagnoses including glaucoma, heart failure, and anxiety, was cognitively intact and required assistance with all activities of daily living. On 3/24/26, the surveyor observed a bottle of Latanoprost eye drops on the windowsill in the resident’s room. The medical record did not show that the resident had been assessed to safely administer medications, there was no physician order for self-administration, and the care plan did not indicate that the resident may self-administer medications. Resident #59, admitted with diagnoses including asthma, sepsis, and congestive heart failure, was also cognitively intact and required assistance with activities of daily living. On 3/24/26, the surveyor observed an Advair inhaler on top of the resident’s bedside cabinet on two separate observations. The resident stated that nurses left the inhaler with him/her to use and that he/she had been self-administering it since admission. The medical record did not show an assessment for safe self-administration, there was no physician order for self-administration, and the care plan did not indicate that the resident may self-administer medications. Nurse #2 stated that residents are not to have medications at the bedside unless they have been assessed to safely self-administer them, and that neither resident had been approved to self-administer medications.
Failure to Implement Physician Orders and Document Care
Penalty
Summary
The facility failed to implement physician orders for eight residents, leading to deficiencies in care. For five residents, the facility did not complete weekly skin assessments as ordered by physicians. These residents, who were at risk for pressure ulcers, did not have documented skin checks in their medical records, despite having orders for weekly assessments. Interviews with the Director of Nursing (DON) and nursing staff confirmed that these assessments were not completed or documented as required. Additionally, the facility did not follow physician orders for three other residents. One resident, who required padded side rails due to seizure precautions, was observed without them. Another resident, who had orders for heel protective boots to prevent pressure wounds, was found without the boots on multiple occasions. A third resident, who had fragile skin and required protective gloves, was observed without them, and there was no documentation of refusal to wear them. The report highlights a systemic issue in the facility's adherence to physician orders and documentation practices. The lack of compliance with these orders was confirmed through interviews with nursing staff and management, who acknowledged the expectations for following and documenting physician orders. The deficiencies were observed during a survey, and the facility's failure to implement these orders as written was evident in the residents' medical records and through staff interviews.
Deficiency in Wound Care Competency Training
Penalty
Summary
The facility failed to ensure that nursing staff were adequately trained and demonstrated the necessary competencies in wound care, as outlined in their Facility Assessment. During the recertification survey, surveyors identified several issues related to wound care, including the failure to implement wound treatments according to physician's orders, failure to obtain new treatment orders when a pressure wound's status changed, and failure to complete weekly skin checks. These deficiencies were observed despite the facility's comprehensive and summarized Facility Assessment Tools, which highlighted the need for specialized care in wound management and required annual competencies for nurses. Interviews with facility staff revealed a lack of awareness and implementation of required wound care competencies. The Assistant Director of Nursing (ADON), responsible for staff competencies and training, admitted to being unaware of the requirement for annual or upon-hire wound care competencies. The ADON also acknowledged that no wound-related competencies, including return demonstrations, had been conducted since she assumed her position. Furthermore, the Director of Nursing (DON) confirmed that wound care competencies should have been completed as indicated in the Facility Assessment, yet none of the three licensed nurses who provided wound care during the survey had evidence of completed wound care competencies since their hire.
Failure to Secure Medication Carts and Medications
Penalty
Summary
The facility failed to ensure that treatment and medication carts were locked when not attended by nursing staff, as required by State and Federal regulations. On multiple occasions, surveyors observed unlocked and unsupervised treatment carts on the fourth floor, with residents and staff walking by. Additionally, a medication cart was found unlocked and unsupervised on the same floor. Unit Manager #2 confirmed that the carts should have been locked when not in the nurse's direct control. Furthermore, a Trelegy inhaler was left unattended on top of a medication cart on the fourth floor, and a blister pack of Escitalopram tablets was left unsecured on top of a medication cart on the fifth floor. Nurse #1 admitted to leaving the Escitalopram unattended while retrieving additional medications from the medication room. These incidents indicate a failure to adhere to the facility's policies on medication storage and security.
Inaccurate Medical Records and Unfulfilled Physician Orders
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in care. Resident #89, who has severe cognitive impairment and epilepsy, was observed multiple times without the required padded side rails on their bed, despite physician orders for seizure precautions. The Treatment Administration Record inaccurately indicated that the padded side rails were present, which was not the case. The Director of Nursing confirmed that orders should not be marked as complete if they are not fulfilled. Similarly, Resident #30, who has Alzheimer's Disease and severe cognitive impairment, was observed with a skin tear and without the prescribed protective coverings on their arms. The physician's orders required the use of geri-gloves every shift to protect the resident's fragile skin. However, the Treatment Administration Record incorrectly showed that the order was completed. The Unit Manager acknowledged that the resident often refuses the gloves, and such refusals should be documented, but emphasized that orders should be followed as written.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident who experienced a 12.6-pound weight gain in one day. The facility's policy requires that nursing leadership or the primary nurse notify the resident, physician, and family when there is a change in condition, such as significant weight gain. Despite this policy, there was no documentation indicating that the physician was informed of the resident's weight gain, which exceeded the threshold outlined in the resident's care plan and physician orders. The resident, who was admitted with chronic diastolic congestive heart failure, end-stage renal disease, and other conditions, showed a pattern of weight gain over several days. The care plan and physician orders specified that any weight gain of 3 pounds in 2 days or 5 pounds in a week should prompt notification to the physician. However, nursing progress notes and MD/NP assessments from the relevant period did not reflect any such notification. Interviews with facility staff confirmed that the physician should have been notified of the weight gain, but this did not occur.
Failure to Implement and Develop Care Plans for Residents
Penalty
Summary
The facility failed to implement a skin integrity care plan for a resident with severe cognitive impairment and multiple diagnoses, including stroke and diabetes. The resident was observed multiple times without the prescribed bilateral heel protectors, which were part of the care plan to prevent skin impairment. Interviews with staff, including a CNA, a nurse, and the unit manager, revealed a lack of awareness and implementation of the care plan, despite the expectation that all care plans should be followed as written. Additionally, the facility did not develop a care plan for the use of antipsychotic medications for another resident with severe cognitive impairment and diagnoses including Parkinson's Disease and toxic encephalopathy. The resident was prescribed two antipsychotic medications, but the interdisciplinary care plans did not include a plan for their use. Interviews with the charge nurse, unit manager, and the director of nursing highlighted a misunderstanding or lack of awareness regarding the necessity of developing specific care plans for residents on antipsychotic medications.
Failure to Implement Care Plan for Resident's Hand Contracture
Penalty
Summary
The facility failed to ensure the medical plan of care was implemented for a resident with a left-hand contracture. The resident, who was admitted in August 2017, has diagnoses including cerebral infarction and hemiplegia, and is at risk for developing pressure ulcers. The physician's orders required the application of an abdominal pad to the resident's left hand to offload the palm from the fingers and to monitor for discoloration and potential wound development. However, observations during the survey revealed that the abdominal pad was not applied, and the discoloration was not monitored as required. The resident was observed multiple times without the abdominal pad in place, and instead, a blue hand roll or a rolled terry cloth towel was used, which did not offload the fingers from the palm as intended. Interviews with nursing staff and CNAs indicated a lack of awareness and understanding of the physician's orders regarding the abdominal pad and the monitoring of the discoloration. The Treatment Administration Record (TAR) showed that the order was signed off with a check mark, but there was no documentation of monitoring the discoloration. The care plan and medical record assessments failed to indicate that weekly skin assessments were completed as per the physician's order. The last documented skin check was dated several months prior, and there was no established monitoring of the discoloration in the resident's left hand. Interviews with the Director of Nursing and Unit Manager revealed a lack of knowledge about the discoloration and how it was being monitored, highlighting a gap in communication and adherence to the resident's care plan.
Failure to Implement Proper Pressure Ulcer Care
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice for a resident with pressure-induced deep tissue damage. The resident was admitted with a sacral deep tissue injury and was prescribed an air mattress to prevent further pressure ulcers. However, the facility did not provide the air mattress until three days after admission, and when it was provided, it was not set to the correct settings as per the physician's orders. The air mattress was observed to be on a firmer setting than prescribed, which could potentially worsen the resident's condition. Additionally, the facility did not follow the physician's wound care orders for the resident's pressure wound. Charge Nurse #1 failed to apply adaptic, a non-adherent wound dressing, as ordered by the physician. The nurse was unaware of the order and only applied calcium alginate followed by a dry protective dressing. This oversight was acknowledged by the Unit Manager and the Director of Nursing, who confirmed that the adaptic should have been applied as per the physician's order. Furthermore, there was a failure to clarify the documented stage of the resident's pressure wound. The resident's wound was treated as a stage two pressure wound, but observations indicated it was a deep tissue injury with intact skin. The treatment provided was not appropriate for the wound's actual condition, and there was a lack of communication and clarification between the nursing staff and the physician regarding the correct treatment. The Director of Nursing and the Regional Nurse Consultant confirmed that the treatments used were not suitable for the resident's wound condition.
Failure to Conduct Required Neurological Checks After Unwitnessed Falls
Penalty
Summary
The facility failed to conduct 72-hour neurological checks for a resident who sustained multiple unwitnessed falls. According to the facility's Falls Management policy, neurological checks are required for 72 hours following any unwitnessed fall or when a resident states or shows evidence of hitting their head. Despite this policy, the facility did not complete the required neurological assessments for six out of ten unwitnessed falls experienced by the resident between September 2024 and February 2025. The resident, who was admitted in April 2022, has a history of repeated falls and is at high risk due to conditions such as legal blindness, unsteady gait, and cognitive communication deficit. The incident reports reviewed by the surveyor indicated that the resident experienced twelve falls, ten of which were unwitnessed. However, the neurological flow sheets for six of these unwitnessed falls were missing, indicating a failure to adhere to the facility's policy. Interviews with the Unit Manager and the Director of Nursing confirmed that the neurological checks were not completed as required. The Director of Nursing acknowledged the missing documentation but was unsure of its whereabouts, highlighting a lapse in the facility's protocol for monitoring and documenting post-fall assessments.
Missing Monthly Medication Review for a Resident
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed a Monthly Medication Review (MMR) for a resident, identified as Resident #8, who was admitted in November 2024. Resident #8 had diagnoses including bipolar disorder, schizophrenia, and diabetes type II, and was prescribed medications such as Trazodone, Zoloft, Risperidone, and Metformin. A review of the resident's MMRs from November 2024 through January 2025 revealed that the MMR for December 2024 was missing. During an interview, the Director of Nursing (DON) confirmed that the MMR for December 2024 was not found in either electronic or paper records, and despite efforts, the missing MMR was not provided by the end of the survey.
Failure to Provide Adaptive Equipment for Resident
Penalty
Summary
The facility failed to provide adaptive equipment, specifically a two-handled cup, to a resident who required it for self-feeding due to hemiparesis following a stroke. The resident was admitted with a diagnosis that included hemiparesis and was cognitively intact, requiring setup and cleanup assistance with eating. Occupational therapy had recommended the use of a two-handled cup to maximize the resident's performance with self-feeding, and a physician's order was placed to ensure the cup was provided with all meals. Despite the order and communication to the dietary department, the resident was observed on multiple occasions without the two-handled cup during meals. Instead, the resident received drinks in cartons with straws, which were not suitable for their needs. The resident expressed difficulty in drinking without the two-handled cup, resulting in prolonged meal times and cold food. The staff, including CNAs and unit managers, were unaware of the requirement for the two-handled cup, and the cup was improperly stored in the resident's room, leading to its non-use. Interviews with the Director of Rehab, Food Service Director, and Director of Nursing revealed a breakdown in communication and procedure adherence. The staff failed to ensure the two-handled cup was available and used during meals, despite it being indicated on meal slips and ordered by the physician. The oversight in transcribing the physician's order into active orders and the improper storage of the cup contributed to the deficiency, highlighting a lapse in ensuring the resident's needs were met as per their care plan.
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,282 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cambridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Neville Center At Fresh Pond For Nursing & Rehab | 0.4 mi | ★★★★★ | 5 | 0 |
| Watertown Rehabilitation And Nursing Center | 1.6 mi | ★★★★★ | 19 | 0 |
| Belmont Manor Nursing Home, In | 1.9 mi | ★★★★★ | 13 | 0 |
| Presentation Rehab And Skilled Care Center | 2.6 mi | ★★★★★ | 3 | 0 |
| Spaulding Nursing And Therapy Center - Brighton | 2.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.