GREGORY WING OF ST ANDREWS VILLAGE

145 EMERY LANE, BOOTHBAY HARBOR, ME 04538 (207) 633-6996
For profit - Corporation 42 Beds Independent Data: November 2025
Trust Grade
40/100
#66 of 77 in ME
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Last Inspection: May 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Gregory Wing of St Andrews Village has a Trust Grade of D, indicating below-average performance with some significant concerns. It ranks #66 out of 77 nursing homes in Maine, placing it in the bottom half of facilities in the state, and it is the second-best option in Lincoln County, meaning there is only one other local facility that is better. Unfortunately, the facility's situation is worsening, with issues increasing from 4 in 2022 to 14 in 2024. Staffing is a relative strength, rated at 4 out of 5 stars, and the turnover is exceptionally low at 0%, which is far better than the state average. However, there are serious concerns regarding safety and sanitation; for example, the facility failed to conduct regular inspections of beds to prevent entrapment risks and did not maintain cleanliness in the kitchen or properly dispose of trash, which could attract pests. While there are some positive aspects, families should weigh these serious issues carefully when considering this nursing home for their loved ones.

Trust Score
D
40/100
In Maine
#66/77
Bottom 15%
Safety Record
Low Risk
No red flags
Inspections
Getting Worse
4 → 14 violations
Staff Stability
○ Average
Turnover data not reported for this facility.
Penalties
✓ Good
No fines on record. Clean compliance history, better than most Maine facilities.
Skilled Nurses
✓ Good
Each resident gets 82 minutes of Registered Nurse (RN) attention daily — more than 97% of Maine nursing homes. RNs are the most trained staff who catch health problems before they become serious.
Violations
⚠ Watch
21 deficiencies on record. Higher than average. Multiple issues found across inspections.
★☆☆☆☆
1.0
Overall Rating
★★★★☆
4.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2022: 4 issues
2024: 14 issues

The Good

  • 4-Star Staffing Rating · Above-average nurse staffing levels
  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record

Facility shows strength in staffing levels, fire safety.

The Bad

1-Star Overall Rating

Below Maine average (3.0)

Significant quality concerns identified by CMS

The Ugly 21 deficiencies on record

May 2024 14 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, record reviews and interviews, the facility failed to provide residents/representatives written inform...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, record reviews and interviews, the facility failed to provide residents/representatives written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for 2 of 6 residents reviewed for advanced directives (Resident's #24 and #26). Findings: Review of facility policy titled Advance Directives effective date 10/1991 states Purpose: To comply with Federal and Critical access hospitals conditions of participation, the Federal Patient Self-Determination Act, the Main Uniform Health Care Decisions Act and to provide the community with a method for healthcare decision making, [NAME] health has adopted this Advance Directive Policy to provide: 1. B. Written information to patients and or their support person concerning their right to make decisions about medical care. C. Documentation of patients declaration of an advanced healthcare directive form. 2.B.1. [NAME] health will provide written information to all adult patients, emancipated minors, persons authorized to make medical decisions on behalf of patients and or the patient support person during every inpatient admission, at time of registration, to outpatients or their representative, to those who are in in emergency department, those undergoing same day surgery, are those who are in observation status. C.4. Any employee or medical staff were receives a copy of Advanced Healthcare Directive form will submit it as part of the patient's medical record . 1. Resident #24 was admitted to the facility on [DATE]. A review of Resident #24's clinical record lacked evidence that the facility provided resident and/or resident's representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. 2. Resident #26 was admitted to the facility on [DATE]. A review of Resident #26's clinical record lacked evidence that the facility provided resident and/or resident's representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. On 5/13 24 at 11:50 a.m., during an interview, the Registered Nurse (RN #2) confirmed the above findings.
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on facility policy, record review and interviews, the facility failed to report in a timely manner, an injury of unknown origin with serious injury to the Division of Licensing and Certification...

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Based on facility policy, record review and interviews, the facility failed to report in a timely manner, an injury of unknown origin with serious injury to the Division of Licensing and Certification (DLC) (State Survey Agency) and to Adult Protective Services (APS) (State Agency) for 1 of 1 residents sampled for injuries/accidents. (#27) Finding: Review of the facility's Abuse. Neglect, and/or Exploitation Reporting Policy # 02-7080-246, effective date: 05/1999, noted in 1. Policy Statement: 2. All personnel who suspect any incident of resident abuse, neglect or exploitation, including injuries of an unknown source or misappropriation of resident property, must promptly report the incident to (the Department of Health and Human Services)DHHS through the Division of Licensing and Regulatory Services(DLRS) within 24 hours of the incident and to Adult Protective Services. Attachment one: 1. All incidents: All incidents must be reported to DHS through the division of licensing and regulatory services DSLRs . Within 24 hours of the incident or the next working day, when the incident occurs or on a holiday or weekend.) . On 3/18/24 at 3:09 p.m., the Division of Licensing and Certification received from the facility a fax which indicated an injury of unknown origin to Resident #27 which was discovered during morning care. A review of Resident #27's clinical record noted a nursing note written by Nursing n 3/15/24 a 10:59 indicating Resident with some right shoulder swelling noted this am during am care/dressing. When sitting on edge of bed, right shoulder is not symmetric, right shoulder appears lower/? dropped compared to left. Resident winces when assisted with dressing. No eventer fall has happened with resident recently. Small rash area noted on right chest and irregular bruise noted on right inner upper arm, non tender. Will try ice and Tylenol and monitor. On 3/15/24 a 2:05p.m., the resident was transported to an acute care hospital emergency room for evaluation. Resident #27 was found to have right humeral head fracture and fracture Compression Thoracic 5, 6,and 7. On 5/13/24 at 10:50 a.m., in an interview, the Director of Nursing stated this injury was discovered on Friday 3/15/24. She went on to state that the facility knew about the serious injury the same evening in a report from the hospital. She further stated that the facility report to the state was not sent in until 3/18/24. On 5/13/24 at 12:10 p.m., in an additional interview, the Director of Nursing confirmed that the facility did not send a report timely to the Division of Licensing and Certification (DLC) (State Survey Agency) and to Adult Protective Services (APS) (State Agency) regarding this injury of unknown origin.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a baseline care plan was developed and implemented within ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the problems, interventions, and initial goals needed to provide minimum healthcare information necessary to properly care for 1 of 3 residents that were reviewed for new admissions. (#189) Finding: On 5/13/24 at 10:25 a.m., During an interview, Resident #189 stated, he/she has a pacemaker which is checked via his/her phone. Resident #189 was admitted to the facility on [DATE]. The hospital history and physical included information that the resident had a pacemaker placed for tachybradycardia syndrome and heart block. Further review indicates resident #189's code status as Do Not Resuscitate. Review of the clinical record lacked evidence of a baseline care plan completed within 48 hours to include the instructions necessary to properly care for Resident #189's immediate health and safety needs for the above concerns. On 5/14/24 at 10:19 a.m., during an interview, the Registered Nurse admission Coordinator confirmed the above and stated she will add the presence of a cardiac pacemaker immediately.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Based on record reviews, interviews and facility policy, the facility failed to update/implement goals and interventions in the area of antibiotic medication use for 1 of 6 residents reviewed for medi...

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Based on record reviews, interviews and facility policy, the facility failed to update/implement goals and interventions in the area of antibiotic medication use for 1 of 6 residents reviewed for medications (Resident #15). Findings: Review of facility policy Care Planning/Interdisciplinary Team/Family Participation dated 3/98 states .A comprehensive care plan is developed within seven days of completion of the resident comprehensive assessment (MDS).Reviewing care plans to assure that: They reflect the resident's actual needs . Review of Resident 15's care plan initiated 3/22/23 revealed .Focus: I have a Urinary Tract Infection; Goal: UTI will resolve without complications; Interventions: Administer antibiotic as prescribed by Provider Review of Resident 15's clinical record revealed order with start date of 2/23/24 for Amoxicillin-Pot Clavulanate 875-125 mg tablet. Give 1 tab by mouth twice daily for 7 days for UTI [Urinary Tract Infection]. Further review of Resident #15's clinical record lacked evidence his/her care plan was updated after this medication was completed. On 5/14/23 at 11:26 a.m., during an interview, the Director of Nursing indicated that Resident #15's care plan should have been updated within 7 days of the antibiotic completion and confirmed the above findings.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility policy, the facility failed to review and revise the care plan by an interdiscipl...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility policy, the facility failed to review and revise the care plan by an interdisciplinary team (IDT) that included, to the extent possible, participation of the resident and/or his/her representative after each assessment for 1 of 7 sampled residents (Resident #17). Findings: Review of facility policy Care Planning/Interdisciplinary Team/Family Participation dated 3/98 states .A comprehensive care plan is developed within seven days of completion of the resident comprehensive assessment (MDS).Reviewing care plans to assure that: They reflect the resident's actual needs . Resident #17 was admitted to the facility on [DATE]. During review of Resident #17's medical record, the surveyor noted quarterly Minimum Data Set (MDS) Assessments dated 2/6/24. The clinical record lacked evidence that a care plan meeting was held by the IDT, resident and/or representative for this assessment. In addition, the last documented IDT meeting was held on 11/14/23. On 5/14/24 at 2:32 p.m., during an interview, the Social Worker reviewed Resident #17's entire clinical record and confirmed there was no evidence that an IDT was held. On 5/14/24 at 2:54 p.m., the above was discussed with Director of Nursing.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0661 (Tag F0661)

Could have caused harm · This affected 1 resident

Based on interview and clinical record review, the facility failed to develop a discharge summary which included a recapitulation of the resident's stay for 1 of 1 residents reviewed for discharge (Re...

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Based on interview and clinical record review, the facility failed to develop a discharge summary which included a recapitulation of the resident's stay for 1 of 1 residents reviewed for discharge (Resident #33). Findings: Resident #33 was admitted to facility on 2/9/24 for skilled services. On 2/24/24 resident #33 was discharged to the community. The clinical record lacked evidence a recapitulation of the resident's stay was completed at discharge. On 5/15/24 at 10:09 a.m., during an interview, the Director of Nursing indicated that she reviewed Resident #33's clinical record and was unable to find evidence that a recapitulation of stay was completed for this resident.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure that the resident's environment was free of accident hazards r...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure that the resident's environment was free of accident hazards relating to a commode for 1 of 3 days of survey. (5/13/24) Finding: On 5/13/24 at 10:05 a.m., two surveyors observed a commode over a toilet in Resident room [ROOM NUMBER]'s bathroom. The left armrest had been worn down and the right armrest was broken open with sharp/jagged plastic edges exposed. On 5/13/24 at 10:13 a.m., in an interview with two surveyors, the Director of Nursing confirmed that the sharp/jagged plastic edges on the armrest was an accident hazard.
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

Based on observations, record reviews and interviews, the facility failed to ensure that clinical records were complete and contained accurate documentation for 1 of 3 sampled residents reviewed for O...

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Based on observations, record reviews and interviews, the facility failed to ensure that clinical records were complete and contained accurate documentation for 1 of 3 sampled residents reviewed for Oxygen (#189). Finding: On 5/13/24 at 10:25 a.m. and on 5/14/24 at 9:56 a.m., observations of Resident #189 on Oxygen set at 2 Liters Per Minute (LPM) via nasal cannula. Review of the hospital discharge history and physical states the resident has diagnosis of chronic respiratory failure with hypoxia and obstructive sleep apnea and required oxygen at home at 2LPM continuously. The Assessment and Plan states, Patient on continuous home oxygen, 2 LPM via nasal cannula. Review of the Physician order dated 5/7/24 states O2 every day and night shift for ILD (Interstitial Lung Disease), the order lacked the amount of oxygen / LPM to be administered. On 5/14/24 at 10:19 a.m., during an interview, both the surveyor and the Registered Nurse (RN) admission Coordinator reviewed the admission orders which indicated the 2LPM. The RN stated she will update the orders immediately to reflect the LPM of oxygen.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and facility policy, the facility failed to establish a system of records of receipt and disp...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and facility policy, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, failed to determine that drug records are in order and that an account of all controlled drugs is maintained, failed to ensure that two people who are authorized to administer medications signed the Shift Count page indicating that they counted all controlled substances at the change of shift for 1 of 2 units reviewed for medication storage ([NAME] Wing). Findings: Review of facility policy Controlled Substance Storage dated 5/1/18 states .At each shift change, or when key are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two appropriately licensed/certified personnel and is documented . 1. Review of controlled substance logbook labeled [NAME] Wing Book #16 index revealed page 81 was blank. Further review revealed page 81 belonged to Resident #27 for medication Lorazepam 2mg [milligram]/ml [milliliter] concentrate take 0.25ml. (5mg) by mouth every hour as needed for anxiety, agitation, nausea. Give 1mg 1hour prn for severe anxiety/SOB/nausea. 2. Review of controlled substance logbook labeled [NAME] Wing, Book #16, revealed that oncoming licensed staff failed to sign the shift count page on 5/11/24 at 19:00 and failed to sign out on 5/12/24 at 07:00. On 5/13/24 at 11:18 a.m., during an interview, the Certified Medication Technician (CMT) indicated that staff do not use the index when they do shift count and they only need one person to sign controlled medications into the controlled substance book. The CMT further indicated that when she does count, she does not use the index and just matches the page numbers in the book with the actual medication cards. On 5/13/24 at11:28 a.m., during an interview, the Registered Nurse (RN2) indicated that staff should be using the index during the shift count, but they had not been. RN2 further indicated that licensed staff were required to sign the controlled logbook at the beginning and end of each shift and anytime the keys were transferred to another person. RN2 further indicated they have one staff member entering controlled medications into the controlled logbook. On 5/13/24 at 12:10 p.m., during an interview with 2 surveyors, the Director of Nursing (DON) reviewed the controlled book, noted index page 81 was blank. At this time, the DON stated the index is the key to reconciliate the controlled medication count, the page should have been filled out, and licensed staff should be signing at the beginning and end of each shift indicating the controlled medication count is correct, confirming the above concerns.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

Based on record review, interview and facility policy, the facility failed to show evidence of documentation to justify the use of psychotropic medications for 2 of 5 residents reviewed for unnecessar...

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Based on record review, interview and facility policy, the facility failed to show evidence of documentation to justify the use of psychotropic medications for 2 of 5 residents reviewed for unnecessary medications (#17 and #28). Findings: Review of facility policy Restraints, Physical/Chemical dated 2/98 states .Psychotropic Medication Implementation: .The facility will follow pharmacy recommendations for indication, gradual dose reduction and monitoring . 1. Resident #17 was admitted to on 10/30/23 with a diagnosis of anxiety. Review of Resident #17's clinical record revealed Pharmacy Review dated 2/28/24 stating Patient has an order for Lorazepam 0.5mg [milligram] tab give 1 tab po [by mouth] as needed. [He/she] uses this medication infrequently. According to the regulations this medication is a psychotropic and requires 2 attempts at a gradual dose reduction in the first year and then every year after. If it is not appropriate to attempt a dose decrease at this time, the provider may wish to document rational for contraindication. [Provider response]: Disagree. Further review of Resident #17's clinical record lacked evidence of a rational for the provider's response. During an interview on 5/14/24 at 3:29 p.m., the Director of Nursing confirmed she had reviewed Resident #17's clinical record and was not able to find any rational for Resident #17's continued use of lorazepam. 2. Resident #28 was admitted to on 11/2/23 with diagnosis of anxiety and depression. Review of Resident #28's clinical record revealed a Pharmacy Review - Note to Attending Physician/Prescriber dated 3/25/24 stating Patient has order for Sertraline 100mg give one tab po qam [every morning]. According to the regulations a gradual dose reduction should be attempted 2 times in the first year and once a year thereafter. Provider might wish to attempt a GDR or document rationale for contraindication at this time. Physician may wish to consider a dosage reduction at this time to ensure patient is on the lowest effective dose. [Provider response]: Disagree. Further review of Resident #28's clinical record lacked evidence of a rational for the provider's response. On 5/15/24 at 10:50 a.m., during an interview, the surveyor discussed the finding with the Administrator and the Director of Nursing at the survey exit meeting.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observations, interview and the facility's Storage - Food and Non Food Items policy effective date: 04/20/12, the facility failed to ensure the kitchen was maintained in a clean and sanitary ...

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Based on observations, interview and the facility's Storage - Food and Non Food Items policy effective date: 04/20/12, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a grease trap base, floor drains, ceiling vents, lights and ceiling tiles; failed to ensure facial hair protection was worn; and failed to ensure foods in the walk-in freezer were dated and/or labeled. Findings: On 5/13/24 from 9:10 a.m. to 9:35 a.m., an initial kitchen tour was conducted with the Food Service Director in which the following findings were observed: > The cement base under the grease trap had chipped/missing paint creating an uncleanable surface. > There were 3 floor drain grates that had chipped/missing paint creating uncleanable surfaces. > There were 3 ceiling vents, above food preparation areas, and surrounding ceiling tiles that were moderately soiled with dust. > The dry storage room had a ceiling vent and a light that were moderately soiled with dust. > There was a male kitchen worker with facial hair that was not wearing facial hair protection while preparing food in the kitchen. > The walk-in freezer had an unlabeled and undated bag of bread and also had a package of unlabeled bacon bits. > The dry storage room had a ceiling vent and a ceiling light that were moderately soiled with dust. On 5/13/24 at 9:35 a.m., in an interview, the Food Service Director confirmed the findings.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Garbage Disposal (Tag F0814)

Could have caused harm · This affected multiple residents

Based on observations and interviews, the facility failed to ensure garbage was properly disposed of and contained to prevent the harborage and feeding of pests for 3 of 3 days of survey (5/13/24, 5/1...

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Based on observations and interviews, the facility failed to ensure garbage was properly disposed of and contained to prevent the harborage and feeding of pests for 3 of 3 days of survey (5/13/24, 5/14/24 and 5/15/24). Findings: 1. On 5/13/24 at 9:00 a.m., a surveyor observed loose, unbagged trash on the ground around the dumpsters. 2. On 5/14/24 at 8:15 a.m., a surveyor observed loose, unbagged trash on the ground around the dumpsters. 3. On 5/15/24 at 8:15 a.m., a surveyor observed loose, unbagged trash on the ground around the dumpsters. On 5/15/24 at 10:50 a.m., in an interview, the surveyor discussed the findings with the Administrator and the Director of Nursing at the survey Exit meeting.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0909 (Tag F0909)

Could have caused harm · This affected most or all residents

Based on interviews, the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entr...

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Based on interviews, the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment for 37 of 37 beds. Findings: On 5/14/24 at 11:42 a.m., a surveyor met with the Director of Facilities and asked for the bed gap measurements and side rail gap measurement documentation. The Director of Facilities stated that he had never heard of those before and he would check with the other maintenance men. He came back and stated that they had never heard of them either. At this time, the Director of Facilities confirmed that the facility had never completed bed gap measurements and/or side rail gap measurements at the facility for any of the resident's beds. On 5/14/24 at 11:50 a.m., in an interview with the Administrator and the Director of Facilities, the Administrator stated that she had never heard of bed gap measurements or side rail gap measurements. At this time, the Administrator confirmed that the facility had never completed bed gap measurements and/or side rail gap measurements at the facility for any of the resident's beds. The surveyor asked for the facility's Bed Safety and Bed Rails policy and procedure. On 5/14/24 at 1:30 a.m., in an interview with the Administrator, she stated that she can't locate any Bed Safety and Bed Rails policy and procedure documentation and can't provide any to the surveyor.
MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0868 (Tag F0868)

Minor procedural issue · This affected multiple residents

Based on review of the quarterly Quality Patient Resident Safety Committee meeting attendance sheets and interview, the facility failed to ensure that the Infection Preventionists attended 4 of 4 quar...

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Based on review of the quarterly Quality Patient Resident Safety Committee meeting attendance sheets and interview, the facility failed to ensure that the Infection Preventionists attended 4 of 4 quarterly meetings. Finding: A review of the quarterly Quality Patient Resident Safety Committee meeting attendance sheets indicate that the Infection Preventionists did not attend the 5/24/23, 8/23/23, 11/15/23 and 2/28/24 quarterly meetings. In addition, the facilities Senior Living Performance Improvement & Safety Plan for 2023/2024 under section Program Organization states, The Senior Living Performance Improvement Committee is a Board Committee . Membership of the Committee shall consist of representation from the following constituents: Administration, Board of Trustees, Quality and Safety, Medical Director and/or designee if unable to attend, Pharmacist, Risk Management, Director of Nursing Services and/or designee if unable to attend and three others members of the facility staff. The improvement plan lacks the federally required Infection Preventionists as a committee member. On 5/15/24 at 8:19 a.m., during an interview, the Infection Preventionist stated she has not attended a Quality Patient Resident Safety Committee meeting recently and that she usually does not attend but the Director of Nursing will present her information. On 5/15/24 at 8:25 a.m., during an interview, the Director of Nursing confirmed the infection preventionists has not attended any of the meetings. In addition, the DON stated she does not have the infection prevention education as the infection preventionist has. On 5/15/24 at 9:27 a.m., during an interview with the Administrator the surveyor confirmed the above finding.
May 2022 4 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on record review, facility policy review, and interview, the facility failed to ensure that neurological assessments were completed as directed by facility policy for 1 of 1 residents who had fa...

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Based on record review, facility policy review, and interview, the facility failed to ensure that neurological assessments were completed as directed by facility policy for 1 of 1 residents who had fallen and sustained a head injury (Resident #21). Finding: The Facility's policy, Fall Prevention, effective 10/1/13, directed staff under Post Fall Interventions: Perform and document vital signs and neurological assessment for any unwitnessed fall or if the patient's head contacts a hard surface e.g. floor or counter, regardless of the absence of apparent neurological injury. Vitals should be performed every 15 minutes times (x) 4, than every hour x 4, then every 4 hours x 48 hours. The Neurological Monitoring Form directed that the assessment was to include the date, time, conscious state, pupil response, pupil size, hand grasp, blood pressure, pulse, respiratory rate and pattern, and nausea/vomiting. Resident #21's clinical record contained documentation under progress notes - On 4/22/22 at 07:00, Resident #21 was found on floor in front of his/her bathroom with walker to his/her left side and to the back. Resident reported he/she knelt down to get his/her briefs out of the dresser drawer and fell backwards hitting his/her posterior head on their walker. Upon inspection, the resident had a small bump (1 inch X 2 inch) on upper posterior head. Ice was applied to bump. Resident #21's clinical record contained documentation under progress notes - On 4/2/22 at 11:10, staff heard a loud bang, entered resident's room and found him/her laying on the floor with his/her head against the wall. The resident stated he/she hit his/her head on the wall. Resident #21 had a moderate sized bump on the left side of the back of his/her head. On 5/4/22 at 7:58 a.m., during an interview with a surveyor, the Director of Nursing confirmed that she was unable to find evidence that the neurological assessments were completed for either of Resident #21's falls in April where the resident ended up with a bump on the head.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0712 (Tag F0712)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Documentation in Resident #21's clinical record stated that the resident was admitted on [DATE]. A Medical Provider visited o...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Documentation in Resident #21's clinical record stated that the resident was admitted on [DATE]. A Medical Provider visited on 12/17/21, reviewed the total plan of care, and wrote a progress note. The next required physican vist and progress note was due by 1/21/22 (with a 10 day grace period). The next date the Medical Provider visited that included reviewing the total plan of care, and wrote a progress note was 5/3/22, 102 days late. On 5/4/22 at 8:45 a.m., during an interview with a surveyor, the Clinical Nurse Manager confirmed that Resident #21 did not have timely required physician visits where the Medical Provider reviewed the total plan of care. She confirmed that Resident #21 did not have visits for the new admission time frame of every 30 days for the first 90 days. Based on record reviews and interviews, the facility failed to ensure that a Medical Provider made required visits, reviewed the total plan of care, and wrote a progress note as often as required for 2 of 13 sampled residents (Resident #7 and #21). Findings: 1. Documentation in Resident #7's clinical record indicated that the physician visited the resident and wrote a progress note on 2/11/22. The next required physician visit and progress note was due by 4/23/22 (with a 10 day grace period was 11 days overdue). On 5/3/22 at 2:43 p.m., in an interview with a surveyor, the Director of Nursing confirmed that the physician visit was late.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

Based on observation, interview, and policy review, the facility failed to ensure that cooked foods were handled in a sanitary manner for 1 of 3 days of survey (5/3/22). Finding: The Facility's policy...

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Based on observation, interview, and policy review, the facility failed to ensure that cooked foods were handled in a sanitary manner for 1 of 3 days of survey (5/3/22). Finding: The Facility's policy, Sanitation - Preparation of Food, revised on 7/21, stated, Do not handle, with bare hands, food items that are to be served uncooked or are ready to eat. Use tongs, deli sheets or gloves when handling these foods. On 5/3/22 at 9:15 a.m., during a tour of the kitchen, a surveyor observed a dietary staff member peeling and touching cooked eggs with bare hands. On 5/3/22 at 11:18 a.m., during an interview with the Food Service Director, a surveyor confirmed this observation.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain the dignity of 2 residents (Residents #7 and #133) related...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain the dignity of 2 residents (Residents #7 and #133) related to urinary collection bags and locomotion during 2 of 3 days of survey (5/2/22 and 5/3/22). Findings: 1. On 5/2/22 at 12:11 p.m., a surveyor observed from the hallway an uncovered urinary catheter collection bag containing urine attached to Resident #133's bed frame. 2. On 5/3/22 at 7:29 a.m. and at 11:37 a.m., a surveyor observed from the hallway an uncovered urinary catheter collection bag containing urine attached to Resident #133's bed frame. At 11:47 a.m., the surveyor discussed with dignity concern with the [NAME] Unit Charge Nurse, Registered Nurse (R.N.). On 5/3/22 at 2:20 p.m., a surveyor observed Resident #7 being transported in a wheelchair down the long term care unit hallway, facing backwards with his/her feet dragging on the floor. The surveyor stopped the R.N. who was locomoting (moving from one place to another) the resident backwards and explained the dignity concern. The R.N. stated Resident #7 couldn't keep their feet elevated. The surveyor asked if there are foot rests for the wheelchair and the R.N. confirmed there are and proceeded to place them on the chair. On 5/3/22 at 2:25 p.m., a discussion with the Administrator, the surveyor confirmed the dignity concerns related to urinary catheter collection bags visible from the hallway and assisting residents with locomotion while facing backwards.
Oct 2020 3 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observations and Interviews, the facility failed to label and date foods found the kitchen reach-in freezer, reach-in r...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observations and Interviews, the facility failed to label and date foods found the kitchen reach-in freezer, reach-in refrigerator, reach-in freezer #2, and the dry storage room in the kitchen and on 2 of 2 kitchenettes ([NAME] and [NAME] Wing kitchenettes), on 2 of 2 separate tours (1013/2020 and 10/16/2020). This deficient practice has the ability to affect all residents of the facility. Findings: 1. On 10/13/2020 from 9:10 a.m. to 9:45 a.m., an initial kitchen tour was completed with the Food Service Director in which the following findings were observed: >The walk-in freezer had two bags of creampuffs and a bag of vegetables that were not dated and labeled.Additionally, the bag of vegetables and one bag of creampuffs were open and not sealed. >The walk-in refrigerator had a bag of sliced apples that were not dated and labeled. >The dry storage room had one large clear bag of M & M's, one large bag of noodles, one bag of powdered sugar, and one bag of brown sugar that were not dated and labeled. >Reach in freezer #2 had three bags of vegetables that were not labeled or dated. Additionally, one of the bags of vegetables was also open and not sealed. >There was trash and debris on the floor under and behind the ice machine. >The grease trap cover, by the three-bay pot sink, was rusty and missing paint creating an uncleanable surface. >The hood exhaust was dirty with dust and the coating on the metal filters was worn off creating uncleanable surfaces. >The large food mixer had dried on food particles on the frame and base. >The grease trap by the dish washer and the food preparation table by the walk-in freezer were supported by untreated cement blocks creating uncleanable surfaces. >The floor drain cover, by the dishwasher, was missing paint creating an uncleanable surface. >The floor drain cover, by the triple bay pot sink, was missing paint creating an uncleanable surface. On 10/13/2020 at 9:45 a.m., the Food Service Director confirmed the findings. 2. On 10/16/2020 from 9:40 a.m. to 9:50 a.m., an Environmental Tour was conducted with the Director of Operations in which the following findings were observed: [NAME] Unit Kitchenette: > There was an open bag of brown sugar in zip lock bag that was not labeled and dated on counter to right of the coffee maker. > The refrigerator had a bag of mushy avocadoes,(that were mushy) that was not labeled and dated. > The right side refrigerator door had a box strawberries that were not dated. > The cupboard, to left of refrigerator, had three opened bags of chips that were not dated or sealed. On 10/16/2020 at 9:50 a.m., the Director of Operations confirmed the findings.
MINOR (B)

Minor Issue - procedural, no safety impact

Safe Environment (Tag F0584)

Minor procedural issue · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and sanitary conditions for 1 of 2 units([NAME] Wing) on 1 of 1 environmental tour. Findings: On 10/16/2020 from 9:25 a.m. to 9:40 a.m., an Environmental Tour was conducted with the Director of Operations in which the following findings were observed: [NAME] Wing: -Resident room [ROOM NUMBER] had a broken base board heater. -Resident room [ROOM NUMBER] had a broken base board heater and the floor was dirty around the base of the toilet. -Resident room [ROOM NUMBER] had a broken base board heater and the floor was dirty around the base of the toilet. -Resident room [ROOM NUMBER] had a fracture pan on the floor behind the toilet and the floor was dirty around the base of the toilet. -Resident room [ROOM NUMBER] had a broken base board heater On 10/16/2020 at 9:40 a.m., the Director of Operations confirmed the findings.
MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0655 (Tag F0655)

Minor procedural issue · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to provide the resident and their representative with a summary of t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to provide the resident and their representative with a summary of the baseline care plan for 11 sampled residents that were newly admitted (#1, #8, #15, #16, #17, #19, #22, #26, #28, #20 & #328). Findings: 1. Resident #1 was admitted to the facility on [DATE]. On 10/15/20, Resident #1's clinical record was reviewed and revealed that it lacked evidence that the resident or resident representative was involved in the development of his/her care plan or that he/she received a summary of the baseline care plan. 2. Resident #17 was admitted to the facility on [DATE]. On 10/15/20, Resident #17's clinical record was reviewed and revealed that it lacked evidence that the resident or resident representative was involved in the development of his/her care plan or that he/she received a summary of the baseline care plan. 3. Resident #19 was admitted to the facility on [DATE] from an acute care hospital. Resident #19's clinical record lacked documentation that Resident #19 and resident representative received a copy of the base line care plan. 4. Resident # 22 was admitted to the facility on [DATE] from an acute care hospital. The facility failed to provide the Resident and Resident representative copies of the baseline care plan. On 10/15/2020 at approximately 11:21 a.m., Resident #22 stated, No one asked me if I wanted any copies of anything. 5. Resident # 328 was admitted to the facility on [DATE] from an acute care hospital. On 10/15/2020 at approximately 12:10 p.m., Resident #328 stated, I never received any kind of care plan, and I don't ever remember being offered any copies of anything. 6. Resident #26 was admitted to the facility on [DATE]. On 10-14-20, Resident # 26's clinical record was reviewed and revealed that it lacked evidence that the resident or resident representative was involved in the development of his/ her care plan or that or that he/she received a summary of the baseline care plan. 7. Resident #8 was admitted to the facility on [DATE]. On 10-15-20, Resident #8's clinical record was reviewed and revealed that it lacked evidence that the resident or resident representative was involved in the development of his/ her care plan or that or that he/she received a summary of the baseline care plan. 8. Resident #28 was admitted to the facility on [DATE]. On 10-16-20, Resident # 28's clinical record was reviewed and revealed that it lacked evidence that the resident or resident representative was involved in the development of his/ her care plan or that or that he/she received a summary of the baseline care plan. 9. Resident #30 was admitted to the facility on [DATE]. On 10-16-20, Resident # 30's clinical record was reviewed and revealed that it lacked evidence that the resident or resident representative was involved in the development of his/ her care plan or that or that he/she received a summary of the baseline care plan. 10. Resident #15 was admitted to the facility on [DATE]. On 10/15/20, Resident #15's clinical record was reviewed and revealed that it lacked evidence that the resident or resident representative was involved in the development of his/her care plan or that he/she received a summary of the baseline care plan. 11. Resident #16 was admitted to the facility on [DATE]. On 10/15/20, Resident #16's clinical record was reviewed and revealed that it lacked evidence that the resident or resident representative was involved in the development of his/her care plan or that he/she received a summary of the baseline care plan. On 10/15/2020 at approximately 11:55 a.m., Care Plan Coordinator (CPC) stated, Way back in the day I would always give them a copy and they would sign it and I would put the copy in their chart, but I found that more often than not they would throw it in the trash, so I stopped giving them copies. I offer them a copy, but I don't have them sign them anymore and I have not been documenting it. On 10/15/2020 at 11:55 Confirmed with CPC no evidence of baseline care plans being offered to resident or resident representative.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
  • • No fines on record. Clean compliance history, better than most Maine facilities.
Concerns
  • • 21 deficiencies on record. Higher than average. Multiple issues found across inspections.
  • • Grade D (40/100). Below average facility with significant concerns.
Bottom line: Trust Score of 40/100 indicates significant concerns. Thoroughly evaluate alternatives.

About This Facility

What is Gregory Wing Of St Andrews Village's CMS Rating?

CMS assigns GREGORY WING OF ST ANDREWS VILLAGE an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Maine, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Gregory Wing Of St Andrews Village Staffed?

CMS rates GREGORY WING OF ST ANDREWS VILLAGE's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes.

What Have Inspectors Found at Gregory Wing Of St Andrews Village?

State health inspectors documented 21 deficiencies at GREGORY WING OF ST ANDREWS VILLAGE during 2020 to 2024. These included: 18 with potential for harm and 3 minor or isolated issues.

Who Owns and Operates Gregory Wing Of St Andrews Village?

GREGORY WING OF ST ANDREWS VILLAGE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 42 certified beds and approximately 31 residents (about 74% occupancy), it is a smaller facility located in BOOTHBAY HARBOR, Maine.

How Does Gregory Wing Of St Andrews Village Compare to Other Maine Nursing Homes?

Compared to the 100 nursing homes in Maine, GREGORY WING OF ST ANDREWS VILLAGE's overall rating (1 stars) is below the state average of 3.0 and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Gregory Wing Of St Andrews Village?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Gregory Wing Of St Andrews Village Safe?

Based on CMS inspection data, GREGORY WING OF ST ANDREWS VILLAGE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Maine. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Gregory Wing Of St Andrews Village Stick Around?

GREGORY WING OF ST ANDREWS VILLAGE has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.

Was Gregory Wing Of St Andrews Village Ever Fined?

GREGORY WING OF ST ANDREWS VILLAGE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Gregory Wing Of St Andrews Village on Any Federal Watch List?

GREGORY WING OF ST ANDREWS VILLAGE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

GREGORY WING OF ST ANDREWS VILLAGE

145 EMERY LANE, BOOTHBAY HARBOR, ME 04538 | (207) 633-6996

D
Trust Grade (40/100)
1.0
CMS Rating
21
Deficiencies

Strengths

  • 4-star staffing

Concerns

  • 1-star rating

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nursinghomedata.org | Data: CMS November 2025