Above average — CMS composite of the measures below.
The next survey window likely opens around October 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 Maine Veterans Home - Augusta during CMS and state inspections, most recent first.
The facility failed to notify the MD and resident representatives of significant changes in condition for two residents, including falls and unwitnessed floor incidents. One resident with dementia and CKD was found on the floor after an unwitnessed self-transfer, but the record lacked evidence that the MD or representative was notified. Another resident had three documented falls, yet the chart lacked evidence that family notification occurred, and the RN manager could not locate documentation of those notifications.
Housekeeping and maintenance services were not adequately provided in multiple resident and common areas. Surveyors observed a ripped couch cushion, a dirty and torn floor mat, dirty caulking around several toilets, a ripped/torn Broda chair for a resident, dirt buildup in a floor grate, and a faded/stained countertop. The Facility Manager and an RN confirmed the findings.
Kitchen Sanitation, Food Labeling, and Plumbing Deficiencies: A surveyor and the FSD observed a dirty wall fan, residue on the food disposal unit, and food/debris on the floor under equipment and stoves. Multiple unlabeled food items were found in the reach-in freezer, walk-in freezer, and dry storage area, and a food prep sink next to the ice machine lacked the required air gap. The FSD and a kitchen staff member confirmed the findings.
A resident was prescribed Olanzapine 5 mg HS, but the order initially listed encephalopathy as the indication. During interview, the RN Mgr stated the diagnosis was incorrect and the provider was updating it; the order later listed behavioral disorders associated with dementia, paranoia, and delusions.
Failure to care plan hearing aid use and storage for a resident who used a hearing aid. The resident’s MDS indicated hearing aid use, but the care plan lacked any hearing aid-related interventions. RN staff were unsure how many hearing aids the resident had or which ear was used, and the DON stated the resident could not manage the device independently and needed staff assistance. The Unit Manager confirmed the hearing aid use and storage had not been care planned.
Failure to Complete Neurochecks After Unwitnessed Falls A resident had two unwitnessed falls, and the facility did not follow its neuro assessment policy after either event. Nursing documentation showed neurochecks were initiated, but only one 15-minute check was recorded after the first fall and the required 30-minute checks were missing; after the second fall, the record also lacked the required 15-minute and 30-minute neuro assessments. The RN Manager confirmed the neuro assessments were not completed.
The facility failed to provide and document written information about the right to accept or refuse treatment and formulate an advance directive for several residents. Interviews with staff confirmed that the process was not consistently followed, as evidenced by the lack of documentation in residents' records.
The facility failed to follow infection control protocols, including proper hand hygiene and PPE use during medication administration. A CNA-M was observed neglecting hand hygiene and glove use, while a resident with MDRO lacked appropriate signage for contact precautions. These deficiencies were noted over three survey days, with staff confirming the absence of required precautions.
A resident did not receive the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) Form 10055 at least two days before the last covered day of Medicare Part A services. The notice, which includes appeal rights and payment liability, was given on the same day services ended, as confirmed by a Social Worker.
A facility failed to update a resident's care plan to reflect changes in behavior monitoring frequency. The resident, with a history of dementia and other disorders, was supposed to have hourly behavioral checks, but these were not conducted as the care plan was not updated after the monitoring frequency was changed to every shift.
Failure to Notify Physician and Family of Resident Falls
Penalty
Summary
The facility failed to ensure that a resident’s physician and representative were notified immediately of significant changes in condition and failed to follow its own Notification of Change in Resident Condition or Treatment Plan policy for 2 of 5 residents reviewed. The policy dated 8/20/24 states that the resident’s representative will be notified when there is a change in the resident’s physical, mental, or psychosocial status, or when the resident is involved in an accident or occurrence, and that, except in medical emergencies, representative notifications will be made within 24 hours. One resident with dementia and chronic kidney disease was found on the floor after an unwitnessed attempt to self-transfer, but the record lacked evidence that the resident’s representative or provider was notified of the fall. The MD stated she did not believe she had been notified of the fall, and the DON confirmed the representative was not notified, while stating the provider was notified in writing but could not produce the note. Another resident had three documented falls, including being found on the bathroom floor, on the floor while using a bedside table as a walker, and on the floor after an unwitnessed self-transfer; the nursing notes indicated family notification was needed or would be done later, but the record lacked evidence that the family was notified of any of the three falls. The RN manager was unable to find documentation showing the family had been notified.
Housekeeping and Maintenance Deficiencies in Resident and Common Areas
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment on Freedom Bay, Eagle's Landing, and in a common area. Surveyors observed a ripped couch cushion outside resident rooms on Eagle's Landing, and the Facility Manager confirmed the finding. In a resident room on Eagle's Landing, a surveyor observed a dirty floor mat with stains and ripped material along the side edges, which RN #1 confirmed. During an environmental tour with the Facilities Manager, surveyors observed multiple areas with dirty caulking around toilets in resident rooms on Freedom Bay, a ripped/torn Broda chair for Resident #24, a common area bathroom with dirty caulking around the toilet, dirt buildup in a floor grate in front of the toilet, a faded/stained countertop behind the sink, and dirty caulking around a toilet in a Delta restroom; the Facilities Manager confirmed these findings.
Kitchen Sanitation, Food Labeling, and Plumbing Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner during an initial kitchen tour. A surveyor and the Food Service Director observed a dusty and dirty wall fan in the dish room, a food disposal unit with dried food particles and dried liquid residue, and food and debris on the floor under equipment and stoves. The facility’s Food Storage and Protection policy/procedure stated that food shall be stored, prepared, served, transported, and distributed with protection from contamination, and that foods removed from original packaging shall be stored in a clean and sanitized container and labeled and dated. The facility also failed to ensure foods were labeled in multiple storage areas and failed to ensure proper plumbing installation to prevent backflow. During the kitchen tour, unlabeled items were observed in the reach-in freezer, walk-in freezer, and dry storage room, including bags of breaded patties, French fries, waffle fries, tater tots, sub rolls, and cereal. A surveyor also observed a food preparation sink next to the ice machine with no required air gap installed. The Food Service Director confirmed the findings, and later the same day a surveyor observed additional unlabeled food items in the Freedom Bay Unit reach-in freezer, which a kitchen staff member also confirmed.
Unnecessary Antipsychotic Medication Ordered With Incorrect Diagnosis
Penalty
Summary
Preventing the use of unnecessary psychotropic medications was not ensured for Resident #107 when the resident’s drug regimen included Olanzapine 5 mg daily at hour of sleep. The physician order dated 5/5/25 listed encephalopathy as the indicated use for the antipsychotic medication, and the resident was reviewed as 1 of 5 residents for unnecessary medications. During interview on 10/1/25 at 12:02 p.m., the RN Manager of Freedom Bay Delta House stated that the diagnosis of encephalopathy was incorrect and that the provider was updating the diagnosis. At 12:19 p.m., the physician order for Olanzapine listed behavioral disorders associated with dementia, paranoia, and delusions as the diagnosis.
Failure to Care Plan Hearing Aid Use and Storage
Penalty
Summary
The facility failed to ensure that a care plan was developed for hearing aids for Resident #3, who was admitted in August 2025 and whose MDS indicated that the resident had and used a hearing aid. Review of the resident’s current care plan, updated 9/2/25, showed no evidence that a hearing aid care plan had been developed or initiated. During an interview, RN #2 stated she thought the resident had only one hearing aid but was not sure and did not know which ear it was in. A surveyor observed the resident eating breakfast with a hearing aid in the left ear. The DON stated that the resident could not manage the hearing aid independently and would need staff assistance for use. The Unit Manager confirmed that the resident’s hearing aid use and storage had not been care planned.
Failure to Complete Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to assess and monitor a resident after unwitnessed falls and did not follow its Neurological Assessments policy and procedure for 1 of 5 residents reviewed for falls. The policy dated 5/8/24 states that a neurological assessment will be completed and documented in ECS after any incident or fall in which a head injury is suspected, and that in an unwitnessed fall the resident will be considered to have hit their head unless he/she can reliably state he/she did not. For Resident #47, a nursing note on 5/14/25 at 8:35 p.m. documented the resident was observed on the floor using a bedside table as a walker, and neurochecks were initiated; however, only one 15-minute check was documented and there was no evidence of the required 30-minute checks, with the next documented neurological assessment not until 5/15/25 at 2:02 a.m. A second nursing note on 5/26/25 at 5:05 p.m. documented the resident was observed on the floor after an unwitnessed fall and stated the resident was trying to go to a different chair; neuro assessments were initiated, but the record lacked evidence of the 15-minute and 30-minute neurological assessments, with the next documented assessment not until 5/27/25 at 3:40 a.m. During interview on 10/02/25, the RN Manager confirmed the neurological assessments were not completed for the falls on 5/14/25 and 5/26/25.
Failure to Provide and Document Advanced Directive Information
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were provided with written information regarding their rights to accept or refuse medical or surgical treatment, formulate an advance directive, or appoint a surrogate. This deficiency was identified for nine out of thirteen residents reviewed for advanced directives. The facility's policy mandates that such information be provided at the time of admission and documented in the resident's medical record. However, the clinical records of these residents lacked evidence of compliance with this policy. Interviews with facility staff, including a Social Worker and the Clinical Director, confirmed that the process of asking residents or their representatives about advanced directives and documenting this information was not consistently followed. The Social Worker acknowledged that residents should be asked about advanced directives upon admission, and if they have one, it should be scanned into the electronic medical record. If a resident does not have an advanced directive, they should be offered assistance to complete one, and any refusal should be documented. However, the records reviewed did not show evidence of these steps being taken. The deficiency was further corroborated during interviews with the Clinical Director and the Director of Nursing, who confirmed that not all residents or their representatives were asked or offered the opportunity to fill out an advanced directive upon admission. This lack of documentation and adherence to policy was evident in the clinical records of the residents reviewed, indicating a systemic issue in the facility's process for handling advanced directives.
Infection Control and PPE Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of practice regarding the use of Personal Protective Equipment (PPE) and maintaining a sanitary environment during a medication pass. On one of the survey days, a Certified Nursing Assistant Medication Technician (CNA-M) was observed administering medication without wearing gloves and neglecting hand hygiene protocols. The CNA-M handled medication and resident care items without washing hands or using hand sanitizer, even after being reminded by surveyors. This lack of adherence to hand hygiene was observed multiple times during the medication pass, including handling a resident's medication and personal items without proper sanitation. Additionally, the facility did not implement enhanced barrier precautions (EBP) for residents with urinary Foley catheters and multi-drug resistant organisms (MDRO). Specifically, Resident #34, who had a diagnosis of MDRO and a urinary tract infection, did not have appropriate signage indicating the necessary precautions for staff and visitors. The absence of signage was confirmed by multiple staff members, including a Certified Nursing Assistant and the Liberty Island Nurse Manager, who acknowledged that the resident was on contact precautions but failed to ensure proper notification at the room entrance. The lack of signage and failure to follow hand hygiene protocols were observed over three days of the survey. Despite the facility's policy requiring clear signage for enhanced barrier precautions, the necessary information was not posted, leading to potential risks of disease transmission. Interviews with staff, including the Director of Nursing, confirmed the oversight, highlighting a systemic issue in implementing infection control measures.
Failure to Provide Timely SNFABN Notice
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) Form 10055 to a resident at least two days prior to the last covered day of Medicare Part A services. The SNFABN, which includes information on appeal rights and liability of payment, was supposed to be given to the resident to inform them of the discontinuation of skilled services. However, the resident received the notice on the same day their services ended, rather than two days in advance as required. This deficiency was confirmed during an interview with the Social Worker, who acknowledged that the notice was not provided in a timely manner.
Failure to Update Resident Care Plan for Behavioral Monitoring
Penalty
Summary
The facility failed to update the comprehensive care plan for a resident with a history of senile dementia, epilepsy with behaviors, delusional disorder, adjustment disorder, and depression. The care plan, last updated in July, identified the resident as having potential for disruptive behavior, including wandering, hitting, pushing, and paranoia. The plan required hourly behavioral checks, but observations in October revealed that no behavior monitoring sheets were present in the resident's room. During an interview, the Unit Manager confirmed that the resident had not been receiving hourly checks, which had been changed to every shift in September, and the care plan had not been updated to reflect this change.
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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 Augusta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Augusta Center For Health & Rehabilitation, Llc | 3.4 mi | ★★★★★ | 12 | 0 |
| Mainegeneral Rehab & Long Term Care - Glenridge | 3.8 mi | ★★★★★ | 13 | 0 |
| Mainegeneral Rehab & Long Term Care - Gray Birch | 4.6 mi | ★★★★★ | 9 | 0 |
| Lakewood A Continuing Care Center | 13.5 mi | ★★★★★ | 24 | 0 |
| Oak Grove Center | 14 mi | ★★★★★ | 1 | 0 |
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