Above average — CMS composite of the measures below.
The next survey window likely opens 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 Maine Veterans Home - So Paris during CMS and state inspections, most recent first.
Missing controlled substance shift count signatures were found on 5 of 5 observed medication and treatment carts. Facility policy required two authorized staff members, including a nurse for Schedule II drugs, to count narcotics at each shift change and document both signatures in the bound book, but multiple day, evening, and night shift entries were missing on Unit B and Unit C carts. The missing sign-offs were reviewed with the DON.
Kitchen sanitation deficiencies were observed during an initial tour with the FSD. Surveyors found residue on the dish machine, food disposal, mixers, shake machine, and dessert cups, a dusty floor fan, an unlabeled and undated sugar bin, and two male kitchen workers with facial hair who were not wearing facial hair protection. The FSD confirmed the findings.
A resident admitted to hospice for end-of-life care had a Significant Change MDS that did not reflect hospice in the Treatments/Procedures section. The clinical record and facility documentation showed the resident was opened to hospice, and the DON confirmed the MDS was initiated but not triggered for hospice.
An expired open Lantus insulin pen was found in the Unit C nurse treatment cart during an observation with an LPN. The pen was dated and labeled with manufacturer instructions to use within 28 days after initial use, and the LPN confirmed it had expired before retrieving a new insulin pen.
The facility failed to provide two residents with written information about their rights to accept or refuse medical treatment and to formulate an advance directive, as required by policy. One resident stated they had an advance directive, but it was not available, and the facility did not follow up. The clinical records for both residents lacked evidence of the facility's compliance with these requirements.
The facility failed to provide trauma-informed care for three residents with PTSD. One resident's care plan lacked interventions despite a history of being a prisoner of war. Another resident's care plan did not specify triggers or interventions, and a third resident's PTSD was overshadowed by dementia, with no trauma-informed care plan in place.
A facility failed to maintain a resident's dignity and confidentiality when a CRN shouted down the hall to inquire about the resident's Enhanced Barrier Precautions related to their Foley catheter. This breach of privacy was acknowledged as a dignity concern by the Assistant Director of Nursing.
A facility failed to follow physician orders for a resident's G-tube care. An RN was observed cleaning the G-tube stoma with faucet water instead of the prescribed normal saline, as per a physician order. The RN confirmed using water routinely, indicating non-compliance with the medical directive.
Surveyors found expired medications and medical supplies available for resident use in two medication rooms. In Unit B, vacutainers used for INR labs were expired, and in Unit C, a tote contained expired over-the-counter medications. The DON and ADON confirmed these items were intended for resident use.
The facility failed to serve food in a sanitary manner, as observed during dining services on the B unit. Dietary staff handed uncovered plates to nursing staff, who then delivered them through various areas without covers, contrary to the facility's policy. The DON acknowledged the practice and noted the absence of food covers in the dining room.
Missing Controlled Substance Shift Count Signatures
Penalty
Summary
The facility failed to ensure that each nurse signed the controlled substance bound book after each shift count for 5 of 5 medication and treatment carts observed. Facility policy stated that Schedule II drugs are to be counted at each shift change or key exchange by two authorized staff members, including one licensed nurse, and that the accuracy of the count is to be acknowledged with both signatures in the bound book. The same policy stated that Schedule 3-5 drugs are to be counted at each shift change or key exchange by two authorized staff members, with accuracy acknowledged by both signatures. During observation of the Narcotic Bound Book on Unit B, Unit C, and the nurse treatment carts, surveyors found multiple missing shift count signatures for both Schedule II and Schedule 3-5 medications. Missing entries were identified on the Unit B nurse treatment cart, Unit B medication cart, Unit C medication cart, Unit C nurse treatment cart for rooms C1 through C16, and Unit C nurse treatment cart for rooms C17 through C32. The missing sign-offs occurred across multiple day, evening, and night shifts. The missing change-of-shift signatures were discussed with the DON during interview.
Kitchen Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner during an initial kitchen tour with the Food Service Director. Surveyors observed dried liquid residue and chemical residue on the sides and top of the dish machine, dried food particles and dried liquid residue on the food disposal, a dusty and dirty large standing floor fan, dried food particles on a shelf-top mixer and its base, dried food particles and dried liquid residue on a large standing floor mixer and its base, dried food particles and dried liquid residue on a commercial shake machine and its base, and approximately one hundred stacked clear plastic dessert cups with dried liquid residue and chemical residue on them. Surveyors also observed a large bin of sugar that was not labeled and dated, and two male kitchen workers with facial hair who were not wearing facial hair protection. The Food Service Director confirmed these findings during interview.
Inaccurate MDS Coding for Hospice Admission
Penalty
Summary
The facility failed to ensure that a Minimum Data Set, Version 3.0 (MDS) was accurately coded for one resident reviewed for hospice services. The resident’s clinical record stated that he or she was admitted to hospice for end-of-life care on 5/17/25, but a Significant Change Assessment with an ARD of 5/23/25 and completed on 5/27/25 did not include evidence in Section Treatments/Procedures that the resident had been admitted to hospice. The facility’s Reason for Significant Change dated 5/20/25 stated that the resident was opened to hospice under the hospice provider on 5/17 and that a significant change MDS had been scheduled. During interview, the DON confirmed that the resident’s Significant Change MDS was initiated but was not triggered for hospice.
Expired insulin pen found in treatment cart
Penalty
Summary
The facility failed to ensure an expired medication was removed from the supply available for use in 1 of 5 medication/treatment carts observed, specifically the Unit C nurse treatment cart for rooms C1 through C16. During observation of the cart with LPN #1, surveyors found an open Lantus insulin pen dated [DATE] with the manufacturer’s instruction to use within 28 days after initial use. LPN #1 confirmed that the insulin had expired and retrieved a new insulin pen.
Failure to Provide Advance 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 and to formulate an advance directive. This deficiency was identified for two residents during a review of the facility's policy on Advance Directives, DNR Orders, and Health Care Decision Making. The policy mandates that all residents receive this information at the time of admission and upon request, in accordance with Maine law. For Resident #30, there was no evidence in the clinical record that the facility provided or obtained the necessary written information concerning the resident's rights. Although the resident stated they had an advance directive, it was not available, and the facility did not follow up to obtain it. Similarly, for Resident #47, the clinical record lacked evidence that the facility provided or obtained the required information. The C-Unit Nurse Manager confirmed that there was no documentation indicating that the resident or their representative was asked or offered assistance in completing an advance directive.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for three residents diagnosed with PTSD. Resident #9's medical records indicated a history of PTSD due to being a prisoner of war, yet their care plan lacked any trauma-informed interventions or identified triggers to prevent re-traumatization. Despite documentation of increased symptoms of depression and PTSD, the Director of Nursing was unaware of the PTSD diagnosis, highlighting a communication gap within the facility. Resident #23's care plan acknowledged the potential for anxiety, anger, and depression but did not specify any triggers or interventions to prevent re-traumatization, despite the resident's expressed desire to avoid such experiences. Similarly, Resident #47, who had a history of PTSD from combat exposure, had no trauma-informed care plan in place. The Licensed Social Worker noted that the resident's vascular dementia overshadowed the PTSD, yet the care plan still lacked necessary interventions to address the PTSD diagnosis.
Breach of Resident Confidentiality and Dignity
Penalty
Summary
The facility failed to maintain the dignity and respect of a resident by not ensuring confidentiality. During an interaction on October 7, 2024, a surveyor observed a Clinical Resource Nurse (CRN) shouting down the hall to inquire about a resident's status on Enhanced Barrier Precautions related to their Foley catheter. This action was witnessed as a breach of confidentiality and a failure to respect the resident's right to privacy. The CRN admitted to typically shouting louder, indicating a disregard for maintaining confidentiality in communication. On October 8, 2024, the incident was discussed with the Assistant Director of Nursing, who acknowledged the concern regarding the resident's dignity. The report highlights the facility's failure to promote care that respects the resident's right to confidentiality, as observed in the interaction involving the CRN and the Registered Nurses (RN) Manager.
Failure to Follow Physician Orders for G-tube Care
Penalty
Summary
The facility failed to adhere to physician orders for the care and maintenance of a Percutaneous Gastrostomy tube (G-tube or PEG-tube) for a resident. During an observation, a Registered Nurse (RN) was seen removing a dirty G-tube split gauze dressing from around the stoma and cleaning the site with faucet water instead of the prescribed normal saline. This action was contrary to a physician order dated August 14, 2024, which specified that the PEG tube stoma should be cleansed with normal saline and split gauze applied daily. The RN confirmed during the observation that she routinely used water for cleaning the site, indicating a deviation from the prescribed medical care.
Expired Medications and Supplies Found in Use
Penalty
Summary
The facility failed to ensure that expired medications and medical supplies were removed from the supply available for resident use. During an observation of Unit B's medication room, surveyors found a flat of vacutainers, used for collecting residents' blood for INR labs, with an expiration date of 9/30/24. The Nurse Manager confirmed these vacutainers were available for use on residents. In Unit C's medication room, surveyors observed a tote containing over-the-counter medications with expired open bottles, including Calcium 600 plus D5 mg, a daily multi-vitamin with minerals, and Aspirin 325 mg, with expiration dates of 6/2024 and 4/2024. The DON and ADON confirmed that these medications were intended for use on residents, as they were part of the overflow from the medication cart.
Failure to Maintain Sanitary Food Service
Penalty
Summary
The facility failed to serve food in accordance with professional standards for food service safety and did not adhere to their own policy and procedure regarding the sanitary delivery of food. During the lunch dining service on the B unit, surveyors observed dietary staff plating food and handing uncovered plates to nursing staff, who then placed the plates on trays and walked them through various areas of the facility without covers. This practice was observed on multiple occasions, including during breakfast and lunch services, where trays of uncovered food were delivered to different wings and rooms without maintaining sanitary conditions. The facility's policy, dated 2023, requires that all foods be covered and delivered promptly after plating to maintain food quality and temperature. However, during the survey, it was noted that there were no food covers available in the dining room, and the Director of Nursing (DON) acknowledged that food had never been covered when transported from the East dining room to other areas. This lack of adherence to policy was confirmed during an interview with the Interim Administrator and the DON, who then took immediate steps to educate staff and request plate covers from the kitchen.
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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 South Paris
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Market Square Health Care Center, Llc | 2.1 mi | ★★★★★ | 4 | 0 |
| Norway Center For Health & Rehabilitation, Llc | 3.3 mi | ★★★★★ | 0 | 0 |
| Pinnacle Health & Rehab Canton | 16.8 mi | ★★★★★ | 34 | 0 |
| Clover Health Care | 18.2 mi | ★★★★★ | 7 | 1 |
| Odd Fellows Health Care Center | 18.5 mi | ★★★★★ | 10 | 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 July 2026) and official state health department websites.