Inspection·October 28, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure adequate supervision for a resident with Lewy Body Dementia to prevent a fall for one (R1) of three residents reviewed for falls on a sample list of three. This failure resulted in R1 falling to the ground and sustaining an acute fracture of the left hip. Findings include:The facility's Falls Guideline policy dated 08/2024 documents the following:Purpose: To consistently identify and evaluate residents at risk for falls and those who have fallen to treat or refer for treatment appropriately and develop an organization-wide ownership for fall prevention to achieve each resident's maximum potential of physical functioning, to prevent or reduce injuries related to falls, to enhance residents' dignity and self-worth, to rehabilitate residents to their fullest potential of function. This policy also documents that the intent of this guideline is to ensure this facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident as identified through the following process: identification of hazards and risks, evaluation, implementation, monitoring, and analysis.On 10/28/2025 at 10:12 AM, R1 was lying flat on his back with his head propped on a pillow and his left arm was in a sling. R1 stated, I have pain in my (groin area) on the left side. R1 did not remember that he had a fall and broke his left hip.R1's electronic medical record documents R1 has a diagnosis of Neurocognitive Disorder with Lewy Bodies and R1's Care Plan dated 9/19/2022 documents R1 has impaired cognitive function or impaired thought processes related to neurocognitive disorder with Lewy Bodies.R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score of five indicating R1 has severe cognitive impairment.R1's Fall Risk assessment dated [DATE] documents R1 is at high risk for falls.R1's Care Plan dated 5/18/2023 documents that R1 has the potential risk of elopement related to cognitive deficit, history of wandering, and walking about aimlessly without purpose. R1's Care Plan dated 8/23/2025 with a revision on 9/02/2025 documents that R1 is at risk for falls related to impaired cognition, poor safety awareness, dementia, shuffling gait, and weakness and at risk for falls with injury related to medications, history of falling, poor balance, unsteady gait, and weakness.R1's Progress Notes dated 8/30/2025 document that R1 had an unwitnessed fall that resulted in R1 sustaining a fracture to his left shoulder, a laceration on the side of his left eye, and a skin tear to R1's left elbow. The facility Fall Investigation for R1's 10/18/25 fall #1830 (10/24/2025) documents a witness statement dated 10/18/2025 from V7 (Certified Nurse Assistant (CNA)) which states, I was filling out paperwork at the desk and then I got up to go to the bathroom and (saw) that (R1) was walking out of his bathroom and begin to lose balance and went down to the floor.R1's Hospital Discharge summary dated [DATE] documents R1 was admitted to the hospital following a mechanical fall at the facility (on 10/18/25) where R1 resides and R1 sustained a left hip fracture. An x-ray report dated 10/18/2025 confirmed that R1 had an acute intertrochanteric fracture of the left femur with soft tissue swelling. In a phone interview (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145469 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Paris 1011 North Main Street Paris, IL 61944 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)