Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
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 Gregory Wing Of St Andrews Village during CMS and state inspections, most recent first.
The facility did not perform regular inspections of bed frames, mattresses, and bed rails for safety, affecting all 37 beds. The Director of Facilities and the Administrator were unaware of the requirement for bed gap and side rail gap measurements, and no policy or procedure documentation was available.
The facility's kitchen was found to have several sanitation issues, including chipped paint on surfaces, dusty ceiling vents and tiles, and a kitchen worker without facial hair protection. Additionally, the walk-in freezer contained unlabeled and undated food items. These deficiencies were confirmed by the Food Service Director.
The facility failed to properly dispose of and contain garbage, as observed over three days, with loose, unbagged trash found around dumpsters. This issue was discussed with the Administrator and DON during the survey Exit meeting.
The facility failed to provide two residents with written information about their rights to accept or refuse treatment and formulate an advance directive, as required by its policy. A review of clinical records showed no evidence of such information being given, and a nurse confirmed these findings.
A facility failed to implement a baseline care plan within 48 hours for a newly admitted resident with a pacemaker for tachybradycardia syndrome and heart block. The resident's clinical record did not include necessary instructions for managing their condition, which was confirmed by the RN Admission Coordinator.
A facility failed to update a resident's care plan regarding antibiotic medication use for a UTI. The care plan was not revised after the completion of the prescribed antibiotic treatment, as confirmed by the DON. The care plan should have been updated within seven days of completing the medication.
A facility failed to review and revise a resident's care plan by an interdisciplinary team (IDT) after each assessment. The resident's medical record lacked evidence of a care plan meeting for a quarterly MDS assessment, with the last documented IDT meeting occurring months prior. This deficiency was confirmed by a Social Worker during a record review.
A facility failed to develop a discharge summary with a recapitulation of a resident's stay. The resident was admitted for skilled services and later discharged to the community. The clinical record lacked evidence of the required documentation, which was confirmed by the DON during an interview.
The facility failed to ensure a safe environment by not addressing a hazardous commode in a resident's bathroom. Surveyors found a commode with a worn-down left armrest and a broken right armrest, exposing sharp plastic edges. The DON confirmed these edges were an accident hazard.
The facility failed to maintain accurate records and accountability for controlled substances, as required by policy. A resident's medication log was incomplete, and staff did not consistently follow procedures for shift counts and documentation. Interviews revealed that staff were not using the index for shift counts, and only one person was signing controlled medications into the logbook, contrary to policy.
The facility failed to document justification for the use of psychotropic medications for two residents. One resident, with anxiety, was prescribed Lorazepam without attempts at gradual dose reduction (GDR) or documented rationale for its continued use. Another resident, with anxiety and depression, was prescribed Sertraline, and similarly, no GDR attempts or rationale were documented. The Director of Nursing confirmed the absence of necessary documentation, leading to a deficiency in compliance with regulations.
A resident's injury of unknown origin, including a right humeral head fracture and thoracic spine compression fractures, was not reported in a timely manner to the Division of Licensing and Certification and Adult Protective Services. The facility's policy requires such incidents to be reported within 24 hours, but the report was delayed, violating the policy. The Director of Nursing confirmed the delay in reporting.
A facility failed to maintain accurate clinical records for a resident on oxygen therapy. The resident, with chronic respiratory failure and obstructive sleep apnea, required continuous home oxygen at 2 LPM. However, the physician's order lacked the specified LPM, only indicating oxygen for ILD. This omission was identified during a review by a surveyor and an RN.
The facility failed to ensure the Infection Preventionist attended required quarterly meetings, as revealed by attendance sheets. The facility's improvement plan also lacked the federally required inclusion of the Infection Preventionist as a committee member. Interviews confirmed the Infection Preventionist's absence, with the DON presenting her information despite lacking equivalent infection prevention education. The Administrator confirmed these findings.
Failure to Conduct Bed Safety Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails for safety, specifically to identify areas of possible entrapment, affecting all 37 beds in the facility. During a survey, the Director of Facilities admitted to the surveyor that he and the maintenance team were unaware of the requirement for bed gap and side rail gap measurements and confirmed that these measurements had never been conducted. The Administrator also confirmed the lack of awareness and absence of any documentation or policy regarding bed safety and bed rails. The facility was unable to provide any policy or procedure documentation related to bed safety and bed rails when requested by the surveyor.
Kitchen Sanitation and Labeling Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during an initial kitchen tour with the Food Service Director. The cement base under the grease trap and three floor drain grates had chipped or missing paint, creating uncleanable surfaces. Additionally, three ceiling vents above food preparation areas and surrounding ceiling tiles were moderately soiled with dust, as were a ceiling vent and light in the dry storage room. A male kitchen worker was observed preparing food without wearing facial hair protection. Furthermore, the walk-in freezer contained an unlabeled and undated bag of bread and a package of unlabeled bacon bits. These findings were confirmed by the Food Service Director during an interview.
Improper Garbage Disposal
Penalty
Summary
The facility failed to ensure proper disposal and containment of garbage to prevent pest harborage and feeding over a three-day survey period. On each day of the survey, loose, unbagged trash was observed on the ground around the dumpsters. These observations were made on 5/13/24 at 9:00 a.m., 5/14/24 at 8:15 a.m., and 5/15/24 at 8:15 a.m. The issue was discussed with the Administrator and the Director of Nursing during the survey Exit meeting on 5/15/24 at 10:50 a.m.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide written information to residents or their representatives regarding their rights to accept or refuse medical or surgical treatment and to formulate an advance directive. This deficiency was identified for two residents during a review of their clinical records. The facility's policy on Advance Directives, effective since October 1991, mandates that written information be provided to all adult patients and their representatives during every inpatient admission and other specified situations. However, the clinical records for Resident #24 and Resident #26 lacked evidence that such information was provided. During an interview, a Registered Nurse (RN #2) confirmed the findings that the facility did not provide the necessary written information to the residents or their representatives. This oversight indicates a failure to comply with the facility's own policy and federal regulations, which require that patients be informed of their rights to make decisions about their medical care, including the formulation of advance directives.
Failure to Implement Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident, which is necessary to address immediate health and safety needs. The resident, who has a pacemaker for tachybradycardia syndrome and heart block, was admitted with a Do Not Resuscitate status. However, the clinical record lacked evidence of a baseline care plan that included the necessary instructions for managing the resident's condition. This deficiency was confirmed during an interview with the Registered Nurse Admission Coordinator, who acknowledged the omission and stated that the presence of a cardiac pacemaker would be added immediately.
Failure to Update Care Plan for Antibiotic Use
Penalty
Summary
The facility failed to update and implement the care plan for a resident regarding antibiotic medication use. The care plan for the resident, who had a urinary tract infection (UTI), was initiated with a focus on resolving the UTI without complications. The intervention included administering an antibiotic as prescribed. However, the clinical record showed that the care plan was not updated after the completion of the antibiotic treatment. The Director of Nursing confirmed that the care plan should have been updated within seven days of the antibiotic completion, but this was not done.
Failure to Review and Revise Care Plan by IDT
Penalty
Summary
The facility failed to review and revise the care plan by an interdisciplinary team (IDT) for one of the sampled residents, Resident #17, after each assessment. According to the facility's policy, a comprehensive care plan should be developed within seven days of completing the resident's comprehensive assessment (MDS). However, during the review of Resident #17's medical record, it was found that there was no evidence of a care plan meeting held by the IDT, the resident, and/or their representative for the quarterly MDS assessment dated 2/6/24. The last documented IDT meeting for Resident #17 was on 11/14/23. This deficiency was confirmed during an interview with the Social Worker, who reviewed the resident's entire clinical record and acknowledged the absence of evidence for an IDT meeting.
Failure to Complete Discharge Summary
Penalty
Summary
The facility failed to develop a discharge summary that included a recapitulation of the resident's stay for a resident reviewed for discharge. The resident was admitted to the facility for skilled services and was discharged to the community. Upon review of the clinical record, there was no evidence that a recapitulation of the resident's stay was completed at the time of discharge. During an interview, the Director of Nursing confirmed the absence of this documentation in the resident's clinical record.
Unsafe Commode Poses Accident Hazard
Penalty
Summary
The facility failed to maintain a safe environment for residents by not addressing an accident hazard in a resident's bathroom. On May 13, 2024, surveyors observed a commode over a toilet in a resident's room with a worn-down left armrest and a broken right armrest, exposing sharp and jagged plastic edges. During an interview, the Director of Nursing confirmed that these sharp edges posed an accident hazard.
Deficiencies in Controlled Substance Management
Penalty
Summary
The facility failed to establish a comprehensive system for managing controlled drugs, which led to deficiencies in record-keeping and accountability. Specifically, the facility did not maintain a detailed record of the receipt and disposition of controlled drugs, making accurate reconciliation impossible. The controlled substance logbook for the [NAME] Wing was found to have a blank page, which should have contained information for a resident prescribed Lorazepam for anxiety and other symptoms. Additionally, the facility's policy required two authorized personnel to conduct and document a physical inventory of all controlled substances at each shift change, but this was not consistently followed. Interviews with staff revealed a lack of adherence to the facility's policies regarding controlled substance management. A Certified Medication Technician admitted that staff did not use the index during shift counts and that only one person was signing controlled medications into the logbook. A Registered Nurse confirmed that staff were not using the index as required and that only one staff member was entering controlled medications into the logbook. The Director of Nursing acknowledged these issues upon reviewing the controlled book, noting the blank index page and confirming that licensed staff should be signing at the beginning and end of each shift to verify the controlled medication count.
Lack of Documentation for Psychotropic Medication Use
Penalty
Summary
The facility failed to provide documentation justifying the use of psychotropic medications for two residents, leading to a deficiency in compliance with regulations regarding unnecessary medications. Resident #17, admitted with a diagnosis of anxiety, was prescribed Lorazepam 0.5mg as needed. A pharmacy review noted the requirement for two attempts at a gradual dose reduction (GDR) within the first year, unless contraindicated, but the provider disagreed without providing a rationale. The Director of Nursing confirmed the absence of documentation supporting the continued use of Lorazepam for this resident. Similarly, Resident #28, admitted with anxiety and depression, was prescribed Sertraline 100mg every morning. A pharmacy review suggested a GDR or documentation of contraindication, but the provider disagreed without providing a rationale. During the survey exit meeting, the Administrator and Director of Nursing were informed of the lack of documentation justifying the continued use of Sertraline for this resident. These findings indicate a failure to adhere to the facility's policy on psychotropic medication implementation, which requires following pharmacy recommendations for GDR and monitoring.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
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) and to Adult Protective Services (APS) for a resident. According to the facility's policy, any suspected incident of resident abuse, neglect, or exploitation, including injuries of unknown source, must be reported to the appropriate authorities within 24 hours. However, the facility did not adhere to this policy. The injury was discovered on 3/15/24 during morning care, when a nurse noted swelling and asymmetry in the resident's right shoulder, along with a rash and bruise. The resident was transported to an acute care hospital the same day and diagnosed with a right humeral head fracture and compression fractures of the thoracic spine. Despite knowing about the serious injury on the evening of 3/15/24, the facility did not report the incident to the state until 3/18/24. The Director of Nursing confirmed in an interview that the report was not sent in a timely manner to the DLC and APS. This delay in reporting violated the facility's policy and the requirement to promptly report such incidents to the appropriate state agencies.
Incomplete Oxygen Therapy Documentation
Penalty
Summary
The facility failed to ensure complete and accurate clinical records for a resident requiring oxygen therapy. Observations on two consecutive days revealed that the resident was on oxygen set at 2 Liters Per Minute (LPM) via nasal cannula. The resident had a history of chronic respiratory failure with hypoxia and obstructive sleep apnea, necessitating continuous home oxygen at 2 LPM. However, the physician's order dated earlier in the month lacked the specified amount of oxygen to be administered, only indicating oxygen for ILD (Interstitial Lung Disease) without the LPM details. This discrepancy was identified during a review of the admission orders by a surveyor and the RN Admission Coordinator, who acknowledged the omission.
Infection Preventionist Absence from Required Meetings
Penalty
Summary
The facility failed to ensure that the Infection Preventionist attended the required quarterly Quality Patient Resident Safety Committee meetings. A review of the attendance sheets revealed that the Infection Preventionist did not attend any of the four quarterly meetings held on 5/24/23, 8/23/23, 11/15/23, and 2/28/24. The facility's Senior Living Performance Improvement & Safety Plan for 2023/2024 also lacked the federally required inclusion of the Infection Preventionist as a committee member. During interviews, the Infection Preventionist confirmed her absence from the meetings, stating that the Director of Nursing (DON) usually presents her information. The DON acknowledged the Infection Preventionist's absence and admitted lacking the infection prevention education that the Infection Preventionist possesses. The Administrator confirmed these findings during an interview with the surveyor.
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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 Boothbay Harbor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Winship Green Center For Health & Rehab, Llc | 10.1 mi | — | 4 | 0 |
| Cove's Edge Inc | 12.2 mi | — | 13 | 0 |
| Horizons Living And Rehab Center | 17.2 mi | — | 0 | 0 |
| Mid Coast Senior Health Center | 17.2 mi | — | 0 | 0 |
| Hawthorne House | 25.1 mi | — | 1 | 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.