Cycle 1
Health 2025-02-26 · Fire 2025-02-26
12 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cambridge, MA
Sancta Maria Nursing Facility
2-star overall rating with 2-star inspections with 12 recent health deficiencies
799 Concord Avenue, Cambridge, MA
(617) 868-2200
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
141
Certified beds
Average residents
126
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-02-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.69
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.55
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
4.19
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.65
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.83
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.54
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.18
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.67
CMS adjusted RN staffing hours
Adjusted total hours
4.11
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
18%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,926
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.29
Composite VBP score used to determine payment impact.
Payment multiplier
0.9864
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.09% · Performance 22.73% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.21% · Performance 8.96% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
10
Baseline 27.83% · Performance 20.18% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
2.52
Baseline 3.50 hours · Performance 3.79 hours · Measure score 2.52 · Achievement 2.52 · Improvement 0.78
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.66% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 379 · Observed rate 11.35% · Lower 95% interval 8.9% |
| Discharge to community | 58.73% |
50.57%
8.2 pts better
|
Better than the National Rate · Eligible stays 417 · Observed rate 53.96% · Lower 95% interval 52.7% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 268 · Denominator 268 |
| Falls with major injury | 0.37% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 268 |
| Discharge self-care score | 17% |
53.69%
36.7 pts worse
|
Numerator 34 · Denominator 200 |
| Discharge mobility score | 30.5% |
50.94%
20.4 pts worse
|
Numerator 61 · Denominator 200 |
| Pressure ulcers or injuries, new or worsened | 1.12% |
2.29%
1.2 pts better
|
Numerator 3 · Denominator 268 · Adjusted rate 1.18% |
| Healthcare-associated infections requiring hospitalization | 8.96% |
7.12%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 253 · Observed rate 8.7% · Lower 95% interval 6.29% |
| Staff COVID-19 vaccination coverage | 8.43% |
8.2%
0.2 pts better
|
Numerator 15 · Denominator 178 |
| Staff flu vaccination coverage | 43.2% |
42%
1.2 pts better
|
Numerator 89 · Denominator 206 |
| Discharge function score | 17% |
56.45%
39.5 pts worse
|
Numerator 34 · Denominator 200 |
| Transfer of health information to provider | 99.44% |
95.95%
3.5 pts better
|
Numerator 178 · Denominator 179 |
| Transfer of health information to patient | 90.48% |
96.28%
5.8 pts worse
|
Numerator 38 · Denominator 42 |
| Resident COVID-19 vaccinations up to date | 31.65% |
25.2%
6.4 pts better
|
Numerator 44 · Denominator 139 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.9
0.4 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.5
0.6 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.2%
7.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.8%
5.2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
3.5%
1.5 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 3.1% · Q4 2.9% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.6% |
12.0%
9.4 pts better
|
11.4%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 3.1% · Q3 1.1% · Q4 1.1% · 4Q avg 2.6% |
| Percentage of long-stay residents who lose too much weight | 6.8% |
5.2%
1.6 pts worse
|
5.4%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 6.2% · Q3 4.5% · Q4 6.6% · 4Q avg 6.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.6% |
19.2%
9.6 pts better
|
19.6%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 8.2% · Q3 8.9% · Q4 6.5% · 4Q avg 9.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.6% |
22.5%
10.9 pts better
|
16.7%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 11.7% · Q3 13.3% · Q4 14.1% · 4Q avg 11.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.9% |
17.7%
1.8 pts better
|
16.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 15.7% · Q3 26.5% · Q4 14.8% · 4Q avg 15.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.1% |
17.6%
10.5 pts better
|
14.9%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 4.8% · Q3 12.8% · Q4 6.0% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
1.0%
0.4 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.8% · Q3 0.8% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
2.0%
0.5 pts worse
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 1.9% · Q3 2.1% · Q4 2.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.8% |
21.7%
2.9 pts better
|
19.8%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 23.7% · Q3 14.8% · Q4 20.4% · 4Q avg 18.8% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
4.6%
0.8 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.6% · Q3 4.3% · Q4 4.5% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.2% |
77.1%
17.1 pts better
|
81.7%
12.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.0% · Q2 94.1% · Q3 96.4% · Q4 94.3% · 4Q avg 94.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.3% |
11.8%
2.5 pts better
|
12.0%
2.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.3% · Observed 9.5% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.3%
0.4 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.8% · Q3 2.3% · Q4 2.8% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.2% |
77.7%
15.5 pts better
|
79.7%
13.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.2% |
25.8%
4.4 pts worse
|
23.9%
6.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.2% · Observed 28.6% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-07 · Fire 2024-03-07
13 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-01-05 · Fire 2023-01-05
13 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-26
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-14
E · Potential for more than minimal harm
2025-02-26
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-04-14
E · Potential for more than minimal harm
2025-02-26
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-04-14
E · Potential for more than minimal harm
2025-02-26
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-02-26
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-02-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-02-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-02-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-02-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-02-26
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-02-26
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-02-26
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2025-04-14
E · Potential for more than minimal harm
2024-03-07
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-03-07
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-03-07
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-03-07
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-03-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-07
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-07
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-07
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-07
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-07
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-07
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-12
F · Potential for more than minimal harm
2023-01-05
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-02-10
F · Potential for more than minimal harm
2023-01-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-10
F · Potential for more than minimal harm
2023-01-05
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-02-10
E · Potential for more than minimal harm
2023-01-05
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-05
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-05
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-05
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-05
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-05
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-02-10
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
Neville Center At Fresh Pond For Nursing & Rehab
Cambridge, MA
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Watertown Rehabilitation And Nursing Center
Watertown, MA
2-star overall rating with 2-star inspections with $69,440 in total fines with 19 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Belmont Manor Nursing Home, In
Belmont, MA
1-star overall rating with 2-star inspections with $18,549 in total fines with 14 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
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