Sancta Maria Nursing Facility

In the surveyor’s words

From the most serious findings on record at Sancta Maria Nursing Facility, in the surveyor’s own words.

• Actual harm, isolatedF689May 7, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF851Mar 25, 2026

  Based 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.Findings include:The surveyor requested, but the facility was unable to provide, a policy regarding Payroll Based Journal (PBJ) reporting. Review of the PBJ Staffing Data Report, Fiscal Year Quarter 1 (October 1- December 31) indicated the following:-Failed to submit data for the quarter: Triggered.-One star staffing rating: Triggered.-Excessively Low Weekend Staffing: This metric is suppressed for this facility and quarter.-No RN (Registered Nurse) Hours: This metric is suppressed for this… […]

• No harm, potential for more than minimal, widespreadF761Jan 5, 2023

  Based on observation and interview the facility failed to store medications in a safe manner in 1 of 2 medication rooms and 3 out of 3 medication carts. Findings include: Review of the facility policy titled Storage of Medications, dated as revised August 2020, indicated that orally administered are stored separately from topical medications. Further review indicated that when the original seal of a manufacturer's container or vial is initially broken, the container or vial will e dated. The nurse shall then place a date opened sticker on the medication and record the date opened with the new date of expiration to be not more than 30 days after opening, unless otherwise directed by the manufacturer. 1. […]

• No harm, potential for more than minimal, widespreadF880Jan 5, 2023

  Based on record review and interview the facility failed to maintain an infection control program designed to help prevent and identify the development and transmission of disease and infection. Findings include: Review of the infection control program failed to indicate the monitoring, tracking and analyzing of infections in the facility for the months of October and November 2022. On 1/05/23, at 11:37 A.M., the surveyor met with the Director of Nursing (DON). She said that she was responsible to ensure that the facility infection control program was effective. During the interview with the DON it was revealed that the facility infection control program did not maintain a detail record of incidents and corrective actions related to infections. […]

• No harm, potential for more than minimal, widespreadF881Jan 5, 2023

  Based on record review, policy review and interview, the facility failed to implement their Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics and failed to complete Antibiotic usage audit tools (Line Listings), which are used to guide decisions for evaluating antibiotic prescribing patterns in accordance with the Antibiotic Stewardship Program. Findings include: Review of the facility policy titled Antibiotic Stewardship, dated July 2017, indicated that all infections will be tracked by the infection preventionist or designee and reviewed for trends. […]