Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 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.
Housekeeping and Maintenance Deficiencies in Resident and Service Areas: A surveyor observed multiple sanitation and maintenance issues throughout the [NAME] Wing, laundry room, kitchen hallway, and activity office, including a broken ceiling tile, heavily soiled floors, cracked and missing floor tiles, stained ceiling tiles, a ripped laundry cart cover, a damaged privacy curtain, dead bugs in ceiling lights, dusty vents, rust on a drying rack, and chipped paint on chair rails. A Maintenance Worker and the ES/Laundry/Housekeeping Supervisor confirmed the findings.
The facility failed to ensure IDT meetings were held within 7 days of completed MDS/ARDs for 3 residents. One resident’s IDT was held before the MDS/ARD was completed, another resident had no evidence of an IDT within the required timeframe, and a third resident’s IDT was held 12 days after the assessment. The LSW stated she believed she had up to 14 days to hold the meeting and had not yet scheduled one resident’s IDT.
A facility failed to maintain sanitary respiratory care supplies for one resident using PRN O2, failed to follow physician O2 orders for another resident whose concentrator was set below the ordered flow, and failed to document O2 use and respiratory monitoring accurately for both residents. Records showed missing TAR entries for PRN O2, inconsistent O2 flow settings versus orders, and tubing that was not documented as changed weekly as required by policy.
Kitchen sanitation, food labeling, and dish machine monitoring deficiencies: During a kitchen tour, a dirty and rusty grease trap cover, dirty floor drain covers with chipped or missing paint, and unlabeled freezer items were observed, along with a male kitchen worker wearing no facial hair covering. A container of milk was past its best used by date, and dish machine dinner temperatures were not monitored and documented for multiple dates. The RD and Administrator confirmed the findings.
Improper Garbage Storage and Disposal: Surveyors observed dumpsters with lids or doors open exposing trash, trash on the ground around the dumpsters, and trash piled in large uncovered receptacles outside the maintenance shop. The Facilities Manager confirmed that staff placed trash in the bins daily and that the bins were not covered, and the Administrator and Facilities Manager confirmed the repeated findings.
Delayed Baseline Care Plan Development: A resident’s clinical record lacked evidence that a baseline care plan with goals and interventions was developed and implemented within 48 hours of admission. An RN Manager reviewed the record and confirmed the baseline care plan was not completed until 4 days after admission.
Failure to Develop Care Plan for Oxygen Use A resident with COPD and aspiration pneumonia was observed using oxygen via NC, and the record showed oxygen therapy orders for dyspnea, comfort, and low O2 saturation. However, the care plan lacked documented goals and interventions for oxygen use until after the survey began, and the Nurse Manager confirmed that a comprehensive care plan had not been developed or implemented for the resident's oxygen use.
Incomplete CNA Annual Performance Evaluations: The facility failed to complete annual performance evaluations timely for 2 CNAs. Two annual appraisals were initiated by the Nurse Mgr, but both had blank signature lines and no evidence the CNAs reviewed or signed them. One CNA stated she did not receive or sign an evaluation, and the Admin said HR told her an employee does not have to sign an evaluation.
CNA1 did not complete the required 12 hours of annual in-service education. Her records showed 7.09 hours of in-service training instead of 12 hours, and the Nurse Manager confirmed the shortfall during review of her training hours.
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.
Housekeeping and Maintenance Deficiencies in Resident and Service Areas
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and sanitary conditions in the [NAME] Wing, the laundry room, the kitchen hallway, and the activity office. During an environmental tour of the laundry room and [NAME] Wing hallway, a surveyor and the Facilities Manager observed a broken ceiling tile over the stackable dryers that had fallen out of place, a dirty and heavily soiled floor, approximately 10 cracked or broken floor tiles, three stained ceiling tiles in the soiled area, and a laundry cart with a ripped cover that was held together with tape. The Facilities Manager confirmed these findings during interview. On a later tour of the [NAME] Wing, a surveyor and a Maintenance Worker observed a privacy curtain missing hooks and hanging down in disrepair in one resident room, dirty flooring around the base of the toilet and two broken or missing floor tiles under the bathroom door in another resident room, and dead bugs in all three ceiling lights in the activity office. During a separate tour of the laundry and kitchen areas, a surveyor and the Environmental Services Laundry/Housekeeping Supervisor observed two heavily dust-covered wall air vents in the kitchen hallway, a kitchen mat drying rack with large amounts of rust on the base, wooden chair rails in the laundry hallway with chipped and missing paint creating uncleanable surfaces, two stained ceiling tiles behind the folding table in the laundry room, and dusty ceiling air vents over both the large dryers and the stackable dryers. The Maintenance Worker and the Environmental Services Laundry/Housekeeping Supervisor confirmed these findings during interview.
IDT Meetings Not Held Within Required Timeframe After MDS Completion
Penalty
Summary
The facility failed to ensure an interdisciplinary meeting was held within 7 days of the completed MDS/ARD for 3 of 14 residents reviewed. Facility policy stated that the comprehensive care plan is to be developed within 7 days of completion of the comprehensive assessment. For Resident 7, the quarterly MDS/ARD was dated 7/18/25, but the IDT meeting was held on 7/16/25, 2 days before the MDS/ARD completion date; during interview, the LSW confirmed the meeting occurred before completion and stated IDTs are supposed to be scheduled within 7 days of the MDS/ARD date. For Resident 35, the admission MDS was completed on 7/30/25, and the record lacked evidence that an IDT meeting was held within 7 days after the assessment; the LSW stated she had not yet scheduled an IDT meeting for this resident. For Resident 19, the quarterly MDS was completed on 5/17/25 and the IDT meeting was held on 5/29/25, 12 days after the assessment. The findings were discussed with the LSW, who stated she thought she had up to 14 days to hold the meeting.
Respiratory Care, Oxygen Orders, and Documentation Failures
Penalty
Summary
The facility failed to maintain a sanitary environment for respiratory care for one resident who used oxygen therapy. An oxygen concentrator was observed in the resident’s room with tubing labeled as last changed on 7/31/25, and the resident stated the oxygen was only used when needed and had last been used a couple of weeks earlier. The resident had diagnoses including COPD and CHF, and the care plan included oxygen therapy related to respiratory illness with interventions to report symptoms of respiratory distress and monitor for related signs and symptoms. The physician order included oxygen as needed for dyspnea/comfort at 1-2 liters per minute via nasal cannula and weekly tubing changes. The facility also failed to follow physician orders for another resident receiving oxygen therapy. That resident was observed wearing oxygen via nasal cannula with the concentrator set at 1.5 L/min on one occasion and 1 L/min on another, despite orders for 2 L/min via nasal cannula as needed and later 2 L/min via nasal cannula every shift for dyspnea and comfort. During interview, an RN stated the resident had recently had aspiration pneumonia and now required continuous oxygen at 2 L/min, and that there was no order to titrate the oxygen flow rate. The Nurse Manager also stated there were no standing orders to titrate oxygen and that the resident should have been on continuous oxygen at 2 L/min per the physician order. The facility further failed to document respiratory assessments and oxygen use completely and accurately for both residents. For one resident, the record showed oxygen was worn during documented O2 saturation checks from 6/5/25 through 8/13/25, but the June and July TAR showed oxygen documented only once, on 6/8/25, with no evidence of use on other dates when oxygen was reportedly being used. For the other resident, the record lacked documentation of when PRN oxygen was applied, the flow rate used, and follow-up assessment of effectiveness, despite staff stating oxygen would be added when saturations dipped into the 80s and later documented in a nursing note. The facility’s oxygen therapy policy required documentation of the rate of flow, route, rationale, frequency and duration, resident tolerance, reason for PRN administration, and pertinent observations, and also required oxygen tubing to be changed weekly.
Kitchen sanitation, food labeling, and dish machine monitoring deficiencies
Penalty
Summary
The kitchen was not maintained in a clean and sanitary manner during the initial kitchen tour with the RD. The grease trap cover was dirty and rusty, three floor drain covers were dirty and had chipped or missing paint creating uncleanable surfaces, and the walk-in freezer contained items that were not labeled and dated, including three packages of a white substance and two large bags of french fries. A bag of french fries and a bag of [NAME] under the freezer compressor also had chunks of ice buildup on them. In addition, a male kitchen worker with facial hair was observed without a facial hair covering, and the RD confirmed these findings during the tour. The facility also failed to follow its food storage and warewashing policies. Reach-in refrigerator #5 contained one 8-ounce container of fat free milk with a best used by date of July 7, 2025. The Dish Machine and Cleaning Records Temperature check sheet showed that dinner time dish machine temperatures were not monitored and documented for multiple dates in May, June, and July 2025. The Administrator later confirmed the missing documentation findings.
Improper Garbage Storage and Disposal
Penalty
Summary
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. Surveyors observed one dumpster with the front right lid open exposing trash, trash on the ground around the dumpsters, and a trash storage area outside the maintenance shop with trash piled in and on 3 large uncovered trash receptacles. The Facilities Manager confirmed that staff placed trash in the bins daily to take to the dumpsters at the end of the day and that the bins were not covered. On subsequent observations, surveyors again found trash on the ground around the dumpsters, trash in 2 of the 3 large uncovered trash receptacles, one dumpster with the right side slide door open exposing trash, and a trash bag on the ground in front of the other dumpster. The Administrator and Facilities Manager confirmed the findings.
Delayed Baseline Care Plan Development
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission for Resident #19. R19 was admitted in February 2025, but the clinical record did not contain evidence that a baseline care plan with goals and interventions, including the instructions needed to provide minimum healthcare information necessary to care for the resident, was completed within the required timeframe. During an interview on 8/12/25 at 4:00 p.m., the Nurse Manager reviewed R19's baseline care plan and confirmed that it was not developed and implemented until 4 days after admission.
Failure to Develop Care Plan for Oxygen Use
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed for a resident's oxygen use. The resident had diagnoses including COPD and aspiration pneumonia, and the quarterly MDS dated 6/9/25 indicated oxygen therapy while a resident. Physician orders included oxygen 2 L/min via nasal cannula as needed for dyspnea, comfort, and/or oxygen saturation below 90%, and later an order for oxygen 2 L/min via nasal cannula every shift for dyspnea and comfort. The resident was observed wearing oxygen via nasal cannula on 8/11/25 at 9:09 a.m. and again on 8/12/25 at 9:00 a.m. Review of the care plan showed no evidence that goals or interventions for oxygen had been implemented until after the start of the survey, and the Nurse Manager confirmed on 8/12/25 at 4:00 p.m. that a comprehensive care plan had not been developed or implemented for the resident's oxygen use.
Incomplete CNA Annual Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations timely, at least once every 12 months, for 2 of 5 CNAs. Review of CNA1's 2024 Annual Performance Appraisal showed it was initiated by the Nurse Manager on 10/10/24 and included an electronic signature statement, but the signature line was blank and there was no evidence that CNA1 reviewed or signed the evaluation. During interview, CNA1 stated she did not receive or sign an evaluation on 8/12/25 and said she worked all day and never went onto a computer. Review of CNA2's 2024 Annual Performance Appraisal showed it was initiated by the Nurse Manager on 10/28/24, also with a blank signature line and no evidence that CNA2 reviewed or signed it. During interview, the Nurse Manager stated that would have been something signed by HR, and during interview the Administrator stated she had spoken with HR and was told an employee does not have to sign an evaluation; when asked how there would be proof the employee received the evaluation and was made aware of concerns, the Administrator replied, "That is a good question."
CNA Annual In-Service Education Deficiency
Penalty
Summary
The facility failed to monitor and ensure that CNA1 completed the required 12 hours of annual in-service education. CNA1 was hired on 4/11/16, and her yearly in-service education records from 4/11/24 through 4/11/25 showed she received 7.09 hours of in-service education instead of the required 12 hours. During a review of CNA1's in-service hours on 8/13/25 at 11:03 a.m., the Nurse Manager confirmed that CNA1 did not receive the required 12 hours of in-service education.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 17 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.