Sancta Maria Nursing Facility

Inspectors wroteBased on records reviewed, interviews and observations, for one of three sampled residents (Resident #1) who was assessed as being at high risk for falls and required staff assistance for bed mobility, the Facility failed to ensure his/her safety was adequately maintained during the provision of care to prevent an incident resulting in serious injury, when on 04/22/26, Certified Nurse Aide (CNA) #1 assisted and rolled Resident #1 onto his/her side, turned away to get a towel and Resident #1 rolled off the bed and fell to the floor. Resident #1 was transferred to the Hospital's Emergency Department (ED) for evaluation and was diagnosed with a left knee laceration measuring seven centimeters (cm) long which required a running lock suture (a continuous suturing technique) to close the wound.

Inspectors wroteBased on record review and interview, the facility failed to electronically submit direct care staffing data to Centers for Medicare and Medicaid Services (CMS) for the entire reporting period, Fiscal Year (FY) Quarter 1 2026 (October 1 - December 31) in accordance with the schedule specified by CMS.

Inspectors wroteBased on observations and interview, 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, the facility failed to maintain Enhanced Barrier Precautions (EBP) as indicated for four Residents (#85, #40, #59 and #119) out of a total sample of 29 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure Advance Directives (written documents that instruct health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) were accurately documented for one Resident (#14) out of a total sample of 29 residents. Specifically, for Resident #14, the facility failed to ensure that Advanced Directives indicated on the MOLST form (Massachusetts Medical Order for Life-Sustaining Treatment form) were consistently documented in the medical record.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that appropriate information was communicated to the receiving health care institutions or providers for one Resident (#130) out of a sample of 29 residents. Specifically, the facility failed to contact the Resident's health care provider and elder at-risk services in the community after the Resident provided verbal intent to leave the facility earlier than outlined in the care plan.

Inspectors wroteBased on observation, record review and interview, the facility failed to follow a physician's order for one Resident (#118) out of a total sample of 29 residents. Specifically, the facility failed to ensure multipodus booties were implemented as ordered.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that a resident who is unable to carry out activities of daily living received the necessary services needed for two Residents (#24 and #125) out of a total sample of 29 residents. Specifically for Residents #24 and #125 the facility failed to provide supervision or assistance during meals for safety with eating.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide treatment and care in accordance with professional standards of practice for one Resident (#41), out of a total sample of 29 residents. Specifically, for Resident #41 the facility failed to ensure wound provider recommendations were implemented for his/her arterial wounds.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#3) out of sample of 29 residents. Specifically, the facility failed to ensure that nursing consistently administered oxygen in accordance with the physician's orders.

Inspectors wroteBased on record review and interview, the facility failed to ensure that residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Specifically, for Resident #25 the facility failed to determine if the Resident had specific triggers and interventions that might mitigate the response to the triggers should they occur.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure medication was secured in locked compartments for two Residents (#40 and #59) out of a total sample of 29 residents. Specifically,1. For Resident #40 the facility failed to ensure eye drops were secured in a locked compartment.2. For Resident #59 the facility failed to ensure an inhaler was secured in a locked compartment.

Inspectors wrote1d. Resident #54 was admitted to the facility in August 2017 and has diagnoses that include but are not limited to cerebral infarction, hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side, contracture of left upper arm, and contracture, left hand. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #54 scored a 13 out of 15 on the Brief Interview for Mental Status exam indicating he/she as cognitively intact. Further, the MDS indicated Resident #54 had functional limitation in range of motion on both his/her upper and lower extremities on one side and is at risk for developing pressure ulcers/injuries. On 2/24/25 at 7:56 A.M., Resident #54 was observed in bed, with an air mattress mechanism affixed to the footboard. Resident #54 was observed to have his/her left hand held in a fist. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, record review, and interview, the facility failed to notify the physician of a change in condition related to a 12.6 pound (lbs.) weight gain in one day for one Resident (#328) out of a total sample of 27 residents.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to 1) implement a skin integrity care plan for one Resident (#89) and 2) failed to develop a care plan for antipsychotic medication use for one Resident (#27) out of a total sample of 27 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure standards of quality of care for 1 Resident (#54), out of a sample of 25 residents. Specifically, for Resident #54 the facility failed to ensure the medical plan of care was implemented by failing to apply an abdominal pad to his/her left-hand and failing to ensure the left-hand discoloration was monitored for wound development.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide care, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for one Resident (#428) out of a total sample of 27 residents. Specifically, a.) the facility failed to implement physician ordered pressure ulcer prevention intervention for an air mattress. b.) the facility failed to ensure an air mattress was at the correct settings. c.) the facility failed to follow wound care orders to apply adaptic (a non-adherent wound dressing) to a pressure wound as ordered by the physician. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, record review and interview the facility failed for 2 Residents (#49 and #27), to ensure their drug regimen was free of unnecessary antipsychotic medication (a medication used to treat psychosis), out of total sample of 27 residents. Specifically, the facility failed to: 1. Ensure for Resident #49, that a prescribed PRN (as needed) antipsychotic medication was limited to 14 days. 2. Ensure Resident #27 had a medical diagnosis indicated for the administration of an antipsychotic medication.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide adaptive equipment for one 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.

Inspectors wroteBased on observations, interviews and policy review, the facility failed to provide a dignified dining experience in the fifth floor dining room.

Inspectors wroteBased on observations, interviews, records review and policy review, the facility failed to develop and/or implement comprehensive person-centered care plans for four Residents (#11, #58, #64, and #68) out of 29 total sampled residents. Specifically, 1. For Resident #11, the facility failed to develop a plan of care for a cardiac loop recorder (a device that records the heartbeat continuously). 2. For Resident #58, the facility failed to implement the plan of care for soft heel boots, padded side rails and non-skid strips. 3. For Resident #64, the facility failed to implement the plan of care for padded bed siderails and fall mats for a resident with history of falls and epilepsy (a disorder of the brain characterized by repeated seizures). 4. For Resident #68, the facility failed to implement the plan of care for offloading heels.

Inspectors wroteBased on interviews, record review and policy review, the facility failed to ensure agency nursing staff were provided with an orientation to the facility's day-to-day operations including charting and documentation for resident care.

Inspectors wroteBased on observations, interviews and policy review the facility failed to ensure staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically, the facility failed to: 1. Ensure treatment carts were locked on one of three nursing units. 2. Ensure medications were stored properly for one Resident (#68) out of a total sample of 29 residents.

Inspectors wroteBased on observations, interviews and policy review, the facility failed to properly store food items to prevent the risk of foodborne illness and in accordance with professional standards for food service safety.

Inspectors wroteBased on observations, interviews and record review, the facility failed to identify and assess the use of mattress bolsters underneath a fitted sheet to bilateral head and foot of the bed as a potential restraint for one Resident (#43) out of a total sample of 29 residents.

Inspectors wroteBased on observation, policy review and interviews, the facility failed to maintain professional standards of practice for two Residents (#111 and #20) out of a total sample of 29 residents. Specifically, 1. For Resident #111, the nurse failed to properly store medication when the Resident was not in his/her room for medication administration. 2. For Resident #20, the facility failed to follow the plan of care for a PICC (a peripherally inserted catheter into the vein used to administer intravenous fluids and medication) dressing change as ordered by the physician.

Inspectors wroteBased on observation, record review and interviews, the facility failed to provide care and services consistent with professional standards for one Resident (#49) who has an arterial venous (AV) fistula, used for dialysis treatment to remove extra fluids and waste product from your blood when the kidneys are not able, out of a total sample of 29 residents. Specifically, the facility failed to ensure that pressure dressings were kept with Resident #49 in case of an emergency related to bleeding of the AV fistula.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a plan of care was developed for trauma-informed care for one Resident (#39), who was admitted to the facility with a diagnosis of post-traumatic stress disorder (PTSD), out of a total sample of 29 residents.

Inspectors wroteBased on records reviewed, policy review and interviews, the facility failed to act upon recommendations made by the Consultant Pharmacist during monthly medication regimen reviews (MRR) for one Resident (#93), out of a total sample of 29 residents.

Inspectors wroteBased on records reviewed, interviews and policy review, the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS) assessment (a test used monitor for adverse consequences of antipsychotic medication) was completed for one Resident (#20), who was receiving antipsychotic medications, out of a total sample of 29 residents.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to maintain accurate medical records for one Resident (#51) out of a total sample of 29 residents. Specifically, the facility inaccurately documented changing a foley catheter (a tube inserted through the urinary tract into the bladder, connected to a drainage bag) for Resident #51.

Inspectors wroteBased on observations, interviews and policy review, the facility failed to ensure that housekeeping staff maintained proper hand hygiene practices on one of three nursing units.