Cycle 1
Health 2025-08-15 · Fire 2025-08-15
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Boothbay Harbor, ME
Gregory Wing Of St Andrews Village
2-star overall rating with 3-star inspections with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
145 Emery Lane, Boothbay Harbor, ME
(207) 633-6996
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
42
Certified beds
Average residents
33
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-04-01
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
1.11
Registered nurse staffing · state 1.03 · national 0.68
LPN hours / resident day
0.39
Licensed practical nurse staffing · state 0.47 · national 0.87
Aide hours / resident day
4.20
Nurse aide staffing · state 2.86 · national 2.35
Total nurse hours
5.71
All reported nurse hours · state 4.35 · national 3.89
Licensed hours
1.51
RN + LPN hours · state 1.49 · national 1.54
Weekend hours
5.00
Weekend nurse staffing · state 3.91 · national 3.43
Weekend RN hours
0.90
Weekend registered nurse coverage · state 0.73 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.27
CMS adjusted RN staffing hours
Adjusted total hours
6.51
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
2,347
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.07
Composite VBP score used to determine payment impact.
Payment multiplier
1.0041
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.11
Performance 20.45% · Measure score 2.11 · Achievement 2.11 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.85
Performance 6.68% · Measure score 3.85 · Achievement 3.85 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
9.06
Baseline 6.38 hours · Performance 5.66 hours · Measure score 9.06 · Achievement 9.06 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.03% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 4.92% · Lower 95% interval 5.75% |
| Discharge to community | 54.63% |
50.57%
4.1 pts better
|
No Different than the National Rate · Eligible stays 54 · Observed rate 59.26% · Lower 95% interval 43.75% |
| Medicare spending per beneficiary | 0.72 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 86.36% |
95.27%
8.9 pts worse
|
Numerator 38 · Denominator 44 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 44 |
| Discharge self-care score | 57.14% |
53.69%
3.5 pts better
|
Numerator 20 · Denominator 35 |
| Discharge mobility score | 31.43% |
50.94%
19.5 pts worse
|
Numerator 11 · Denominator 35 |
| Pressure ulcers or injuries, new or worsened | 2.27% |
2.29%
About the same
|
Numerator 1 · Denominator 44 · Adjusted rate 3.18% |
| Healthcare-associated infections requiring hospitalization | 6.68% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 2.56% · Lower 95% interval 2.88% |
| Staff COVID-19 vaccination coverage | 8.05% |
8.2%
0.1 pts worse
|
Numerator 12 · Denominator 149 |
| Staff flu vaccination coverage | 99.32% |
42%
57.3 pts better
|
Numerator 146 · Denominator 147 |
| Discharge function score | 45.71% |
56.45%
10.7 pts worse
|
Numerator 16 · Denominator 35 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 26 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | 35% |
25.2%
9.8 pts better
|
Numerator 7 · Denominator 20 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.4
1.1 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.8 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.5 |
2.1
1.4 pts worse
|
1.8
1.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 3.3 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
90.7%
9.3 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% |
95.5%
4.5 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 | 11.0% |
4.3%
6.7 pts worse
|
3.3%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 12.0% · Q3 8.3% · Q4 8.3% · 4Q avg 11.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.3% |
10.7%
7.4 pts better
|
11.4%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 0.0% · Q3 0.0% · Q4 4.2% · 4Q avg 3.3% |
| Percentage of long-stay residents who lose too much weight | 1.3% |
5.5%
4.2 pts better
|
5.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 0.0% · 4Q avg 1.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.2% |
17.0%
11.8 pts better
|
19.6%
14.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 9.5% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.6% |
21.0%
0.4 pts better
|
16.7%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
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 | 24.1% |
29.6%
5.5 pts better
|
16.3%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.6% |
25.7%
2.9 pts worse
|
14.9%
13.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 28.6% · 4Q avg 28.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 15.4% |
1.3%
14.1 pts worse
|
1.0%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 13.9% · Q3 19.1% · Q4 12.7% · 4Q avg 15.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 12.1% |
2.7%
9.4 pts worse
|
1.7%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 8.0% · Q3 8.7% · Q4 4.2% · 4Q avg 12.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.7% |
29.8%
3.9 pts worse
|
19.8%
13.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.8% · Q2 25.8% · 4Q avg 33.7% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
4.4%
2.1 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 6.5% · Q3 0.0% · Q4 0.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
71.2%
28.4 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.2% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.8% |
15.6%
3.2 pts worse
|
12.0%
6.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.8% · Observed 16.7% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.4%
0.1 pts worse
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.7% |
74.5%
15.2 pts better
|
79.7%
10 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.4% |
20.5%
4.9 pts worse
|
23.9%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.4% · Observed 19.4% · Expected 18.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-15 · Fire 2024-05-15
14 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Cycle 3
Health 2022-05-04 · Fire 2022-05-04
4 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-08-15
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-08-15
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-08-15
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-08-26
D · Potential for more than minimal harm
2025-08-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-08-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-12
F · Potential for more than minimal harm
2024-05-15
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-06-28
F · Potential for more than minimal harm
2024-05-15
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-05-15
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-05-15
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-05-15
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-05-15
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-05-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-05-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-28
D · Potential for more than minimal harm
2022-05-04
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-05-19
D · Potential for more than minimal harm
2022-05-04
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-05-19
C · Minimal harm
2022-05-04
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-05-19
B · Minimal harm
2022-05-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-05-19
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-15
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-09-30
E · Potential for more than minimal harm
2025-08-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-09-30
E · Potential for more than minimal harm
2025-08-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-30
E · Potential for more than minimal harm
2025-08-15
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 2025-09-30
E · Potential for more than minimal harm
2025-08-15
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-09-30
D · Potential for more than minimal harm
2025-08-15
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-09-30
D · Potential for more than minimal harm
2025-08-15
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 2025-09-30
D · Potential for more than minimal harm
2025-08-15
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-09-30
D · Potential for more than minimal harm
2025-08-15
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-09-30
F · Potential for more than minimal harm
2024-05-15
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2024-06-21
E · Potential for more than minimal harm
2024-05-15
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 2024-06-21
E · Potential for more than minimal harm
2024-05-15
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-15
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-15
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-15
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 2024-06-21
D · Potential for more than minimal harm
2024-05-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-15
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-15
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 2024-06-21
D · Potential for more than minimal harm
2024-05-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-05-15
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-05-15
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 2024-06-21
B · Minimal harm
2024-05-15
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-06-21
E · Potential for more than minimal harm
2022-05-04
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 2022-06-03
D · Potential for more than minimal harm
2022-05-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-06-03
D · Potential for more than minimal harm
2022-05-04
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2022-06-03
D · Potential for more than minimal harm
2022-05-04
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 2022-06-03
Penalties and ownership
What sits behind the stars
Ownership
Mainehealth Services
5% Or Greater Direct Ownership Interest · Organization
Alamo, Aquilino
Operational/Managerial Control · Individual
Bayman, Charles
Corporate Officer · Individual
Beaule, Lisa
Corporate Director · Individual
Boothby, Leslie
Corporate Director · Individual
Bresnahan, Ann
Corporate Director · Individual
Chin, Matthew
Corporate Director · Individual
Coster, Katherine
Corporate Director · Individual
Elkins, Kelly
Corporate Officer · Individual
Fisher, Morris
Corporate Director · Individual
Hasenfus, Nancy
Corporate Director · Individual
Hentzel, Quincy
Corporate Director · Individual
Herlihy, Kathleen
Corporate Director · Individual
Hunter, Robert
Corporate Officer · Individual
Inzana, Lugene
Corporate Officer · Individual
Kelsch, Beth
Corporate Officer · Individual
Kumaki, David
Corporate Director · Individual
Loffredo, Brett
Corporate Director · Individual
Loiselle, Daniel
Corporate Director · Individual
Mainehealth Services
Operational/Managerial Control · Organization
Manning, Peter
Corporate Director · Individual
Mccarthy, Marie
Corporate Director · Individual
Morrell-Rooney, Sandra
Corporate Director · Individual
Mueller, Andrew
Corporate Officer · Individual
Noyes, Brian
Corporate Director · Individual
Orlando, Matthew
Corporate Director · Individual
Printy, Wayne
Corporate Officer · Individual
Rand, Amanda
Corporate Director · Individual
Rose, Katharine
Operational/Managerial Control · Individual
Ryan, Thomas
Corporate Director · Individual
Shanklin, Heather
Corporate Officer · Individual
Smith, Melissa
Corporate Director · Individual
Terry, Linda
Corporate Director · Individual
Tutt, Dawn
Operational/Managerial Control · Individual
Watson, Stuart
Corporate Director · Individual
Wood, Peter
Corporate Director · Individual
Wusterbarth, Cheryl
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Winship Green Center For Health & Rehab, LLC
Bath, ME
3-star overall rating with 3-star inspections with 13 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Cove's Edge Inc
Damariscotta, ME
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Horizons Living And Rehab Center
Brunswick, ME
4-star overall rating with 3-star inspections with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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