Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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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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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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 | — | 0 | 0 |
| Watertown Rehabilitation And Nursing Center | 1.6 mi | — | 2 | 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 |
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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.