Health inspection·November 13, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Fracture, Type 2 Diabetes mellitus with Hyperglycemia and Diabetic Neuropathy, Asthma, Chronic Obstructive Pulmonary Disease, Hallucinations, Cord Compression, Spinal Stenosis, History of Transient Ischemic Attack, Cerebral Infarction, Hypertension, and History of Alcohol Abuse.R2's undated Care Plan documents diagnoses including Unspecified Dementia, Unspecified Severity, With Other Behavioral Disturbance, and Post Traumatic Stress Disorder. The Care Plan documents R2 has behaviors related to diagnosis of dementia, and history of Post Traumatic Stress Disorder. The Care Plan documents R2 has episodes of being physically aggressive toward others, and that R2 is resistant to care with new intervention dated 7/25/25 to increase supervision and resident will be placed on 10-minute checks.On 11/10/25 at 11:12 AM, R3 stated she was sitting on her four wheeled walker yesterday and waiting in line to go out to smoke and put on her brakes to her walker before standing up. R3 stated that when she stood up and turned around R2 was in her face and punched her in the right shoulder. R3 stated she was scared, and her first reaction was to hit him back, but she didn't and instead told him Don't touch me, don't you ever touch me again. R3 stated R2 said I told you I was coming! R3 stated it doesn't matter what he thinks he told me; he should never touch me.On 11/13/25 at 9:41 AM, R8 confirmed that he witnessed the incident on 11/09/25 between R2 and R3. R8 stated R3 was sitting on her walker next to him and they were waiting to get their cigarettes before they went outside to smoke. R8 stated R2 came up behind R3 and firmly, with an open hand grabbed R3's right shoulder. R8 stated R3 was mad as can be and shocked that R2 touched her. R8 stated R3 snapped at R2 to stop touching her and R2 backed off. R8 stated this wasn't the first time the facility has had this kind of trouble with R2. R8 stated R2 has attempted to hit R8 several times but never made contact and that R2 rammed his wheelchair into another resident on purpose. R8 stated R2 does not respect other people's space, especially women, going into their rooms constantly especially the room across the hall from R8. R2's progress notes dated 10/20/25 document R2 raised a fist and swung at another resident because the other resident was in his way.R2's Physician Visit Note dated 11/10/25 documents R2 has dementia, requires redirection and cuing for safety, is impulsive, and has poor safety awareness. The Note documents R2 was recently in the hospital for acute psychiatric services and is now on therapy services. The Note documents R2 is inconsistent and difficult to re-direct at times and that R2 has behaviors frequently.On 11/10/25 at 12:55 PM, V8 (Licensed Practical Nurse (LPN)), stated that R2 is one on one with her during her shifts. V8 LPN stated that she keeps R2 with her while caring for all 27 of her other residents and that during those times R2 is pleasant. V8 stated that R2 has past trauma and dementia and that he often has increased behaviors in the evening time. V8 stated she has reported to facility management multiple time about R2's increased behaviors.On 11/10/25 at 11:26 AM, V5 (Certified Nursing Aide (CNA)) stated R2 is very confused all the time and sometimes is angry (cusses, doesn't follow directives) and goes into other resident rooms. On 11/10/25 at 11:00 AM V11, CNA when asked about R2 stated, I don't know how to answer that. V11 CNA stated R2 is complete one on one at times.On 11/10/25 at 1:04 PM, V6 RN stated R2 has dementia, and he wanders quite a bit. V6 RN stated that after the altercation on 11/09/25 involving R2 and R3, V4, (Director of Nursing (DON)) told V6 to separate R2 and R3 and since there were three CNAs one was to stay with R2 and try to engage him in an activity.On 11/12/25 at 9:00 AM, R2 was observed self-transferring from a stationary chair to a wheelchair without assistance. R2 was able to take several steps without assistance.On 11/12/25 at 11:06 AM, V14 (Licensed Practical Nurse (LPN)/Care Plan Coordinator/MDS) stated 10-minute checks were put in place for R2 in July because R2 required increased supervision. V14 stated that on 10/24/25 the facility implemented a doorway sensor for R2 as an audible alert to staff that they needed to assess R2's whereabouts immediately when that alarm sounds. V14 verifies that door sensor was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145469 If continuation sheet Page 2 of 6 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 11/13/2025 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)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete implemented on care plan.On 11/13/25 at 9:03 AM, V4 DON stated she was aware of the incident between R2 and R3 and the allegation that R2 hit R3. V4 DON stated after the incident occurred, she instructed V6 RN to do a head-to-toe assessment of R2 and R3 and to keep a close eye on R2. V4 DON stated that R2 was not able to recall the incident, stating R2 is typically Alert and Oriented time one-two, sometimes he makes sense and sometimes he doesn't. V4 DON stated the facility had interventions in place including 10-minute checks to keep a close eye on R2 and that after the above-mentioned incident they moved R2 to the back (secured unit) and V4 DON stated R2 has only hit a CNA once since being back there. V4 DON stated R2 recently swung his fist at her because V4 DON asked R2 if he had a list of things he was going to do that day. V4 DON stated she has been advocating to move R2 to the facility's dementia unit for a long time but that the Intradisciplinary Team had concerns about the noise level in that unit and how it would affect R2. V4 stated I can't predict if R2 will hit someone again, staff will still need to keep a close eye on him. R2 is who he is. Event ID: Facility ID: 145469 If continuation sheet Page 3 of 6 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 11/13/2025 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)

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 develop and implement interventions and provide supervision to prevent a wandering resident from entering other resident's rooms invading resident privacy, disturbing the environment, taking assistive devices, and making inappropriate comments for five (R1, R5, R6, R7, R8) of five residents reviewed for accidents on a sample list of eight. This failure resulted in R1 falling on two separate occasions when R2 took R1's walker and sustaining a laceration to the knee requiring six sutures, a laceration to the left hand and a hematoma to the scalp. Findings include: R2's undated Care Plan documents diagnoses including Unspecified Dementia, Unspecified Severity with Other Behavioral Disturbance and Post Traumatic Stress Disorder (PTSD). The Care Plan documents R2 has behaviors related to diagnosis of Dementia, and history of PTSD. The Care Plan documents R2 has episodes of being physically aggressive towards others and that R2 is resistant to care with new interventions dated 7/25/25 to increase supervision and that R2 will be placed on 10-minute checks.R2's document titled 15 Minute Checks documents as follows: 11/4/25 blank from 6:15 AM to 5:45 PM, 11/7/25 blank from 6:15 PM to 11:45 PM, 11/10/25 no documentation, and 11/11/25 blank from 12:00 AM to 3:45 AM and 8:45 AM to 11:45 PM.R2's Progress Note dated 10/20/25 documents R2 raised a fist and swung at another resident because the other resident was in R2's way.R2's Progress Note dated 10/30/25 documents R2 wandering into other resident rooms without permission. R2 redirected. Behavior continues.R2's Physician Visit Note dated 11/10/25 documents R2 has Dementia, requires redirection and cuing for safety, and that R2 is impulsive and has poor safety awareness. The Note documents R2 was recently in the hospital for acute psychiatric services and R2 is now on therapy services. The Note documents R2 is inconsistent and difficult to redirect at times and R2 has frequent behaviors.R1's Care Plan, undated, documents R1 is [AGE] years old with an admission date of 7/28/25. The Care Plan documents R1 is independent with bed mobility, transfers, and toileting. The Care Plan documents R1 has diagnoses that include heart disease, atrial fibrillation, osteoporosis, low back pain, bilateral lower limb swelling, lump/mass, and that R1 is taking blood thinners. R1's Progress Notes dated 11/1/25, document R1 was found on the floor with her head resting on the table that her refrigerator sits on. A laceration was noted to the left hand. Resident was alert and oriented times four and denied any pain other than her hand. The Progress Notes document R1 stated that she hit her head during the fall. The Progress Notes document Emergency Medical Services were notified.R1's progress notes do not document a fall on 11/4/25.R1's Hospital Records dated 11/1/25 and 11/4/25 document R1 was sent to the emergency department for falls in the early morning hours on 11/1/25 and 11/4/25. On 11/1/25 hospital records document R1 was discharged at 4:02AM with a laceration of the finger of the left hand, hematoma of the scalp and fall. On 11/4/25 hospital records document R1 was discharged at 4:50AM with a laceration of left knee and a head injury. The facility investigation file dated 11/4/25 documents on 11/4/25 at approximately 0200 AM, R1 had an unwitnessed fall in R1's room related to walker not in reach of resident. The investigation documents R1 was attempting to toilet self when legs gave out. R1 alert and oriented times four. R1 hit R1's head on the bedside table next to the recliner where R1 was found by staff post fall. The investigation documents R1 did not have proper footwear on at the time of the incident and was not utilizing an assistive device. The investigation documents R1 was sent to the Emergency Department for complaints of knee pain and pain to left side of face. R1 returned to the facility with sutures to the left knee. The investigation file documents a new fall intervention of -- placed sign in room to remind R1 to use walker when ambulating. On 11/10/25 at 10:58 AM, R1 was observed walking from the bathroom to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145469 If continuation sheet Page 4 of 6 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 11/13/2025 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few recliner using a rolling walker and wearing non-skids socks. R1 had a large purple area across R1's forehead and a purple area across the bridge of R1's nose. R1's cheek was swollen and pink. R1's left palm was purple throughout with a laceration to R1's 5th finger.At 11:00 AM on 11/10/25, R1 stated that when she went to the bathroom, the first time she fell on [DATE], R2 entered her room and moved her walker out of reach over by her bed and was sitting on her bed trying to tear apart her call light. R1 stated that R2 proceeded to tell her when he was done with the call light, he was going to put her in bed and have sex with her. R1 stated she screamed for help, but no one came to her aide. R1 stated the second time she fell on [DATE], R2 was in her room again and moved her walker out of reach while she was in the bathroom. R1 stated this fall caused her to hit her head and receive six stitches to her knee. R1 stated she is fearful of R2 and that he was in her room last night on 11/9/25 as well. R1 stated R2 is always coming in her room and threatening her, and she is very scared. R1 stated that no one believes her and that now even her own son believes she is making these things up.On 11/12/25 at 9:35AM, R5 stated that R2 would enter his room about four to five times a night, at times he was using the restroom, or changing, other times he would be sleeping and awake to R2 grabbing his toes or going through his belongings. At one point, R2 had taken his wallet and R2's spouse returned it to him. R5 stated he is the [NAME] President of Resident Council and that many of the residents, especially female residents, have approached him complaining of R2 entering their rooms and frightening them stating they don't feel safe in the facility anymore. R5 stated that the facility doesn't seem to be doing anything about it.On 11/12/25 at 9:39AM, R6 stated I'm just afraid sometimes. R6 stated that when R2 resided on her hall he would come in her room and grab her toes and sometimes she would wake up and R2 would be standing over her staring. R6 stated she would tell R2 to get out of her room and R2 would leave but sometimes R2 wouldn't and R6 had to call staff for help.On 11/12/25 at 10:00AM R7 stated that R2 would come in his room multiple times throughout the night. R7 stated he does not get much rest and therefore is sleeping most of the day. R7 stated he is not able to function as he normally would on regular sleep.On 11/13/25 at 9:41 AM, R8 stated R2 has attempted to hit R8 several times but never made contact and that R2 rammed his wheelchair into another resident on purpose. R8 stated R2 does not respect other people's space, especially women, going into their rooms constantly especially R1's room directly across the hall from R8. On 11/10/25 at 12:55 PM, V8 Licensed Practical Nurse (LPN), stated that R2 is one on one with her during her shifts. V8 stated that she keeps R2 with her while caring for all 27 of her other residents and that during those times R2 is pleasant. V8 stated that R2 has past trauma and dementia and that he often has increased behaviors in the evening time, but night shift does not watch him. V8 stated she has reported to facility management multiple times about R2's increased behaviors. On 11/10/25 at 11:26 AM, V5 CNA stated R2 is very confused all the time and sometimes is angry (cusses, doesn't follow directives) and also goes into other resident rooms. On 11/12/25 at 9:15 AM, V13 Activity Director, stated that R1 is part of her morning rounds and that on 11/1/25, R1 reported to her that R2 had come into her room during the night and taken her walker while she was in the bathroom. R1 reported that when she opened the bathroom door, R2 was sitting on her bed in his underwear only and had her walker. V13 stated that while R1 was in the hospital she was distraught, crying, and scared and pleading with staff not to send her back to the facility. V13 stated that R2 has been a constant topic during Resident Council Meetings and is frequently brought up during Interdepartmental Team Meetings due to his behaviors and repeated offenses of entering resident rooms at night and scaring residents. V13 stated the staff are supposed to be doing 10-minute safety checks on R2, however she has seen him in activity room for hours at a time without any staff members checking on him.On 11/10/25 at 10:58 AM, V7 LPN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145469 If continuation sheet Page 5 of 6 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 11/13/2025 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete (Agency) stated that it was reported to her this morning that R2 was awake until 2:00 AM and was going into other resident rooms during the night.On 11/10/25 at 11:00 AM V11, Certified Nursing Aide (CNA), when asked about R2, stated, I don't know how to answer that. V11 stated R2 is complete one on one at times.On 11/12/25 at 9:00 AM, R2 was observed self-transferring from a stationary chair to a wheelchair without assistance. R2 was able to take several steps without assistance. On 11/12/25 at 11:06 AM, V14 Licensed Practical Nurse (LPN)/Care Plan Coordinator/MDS stated 10-minute checks were put in place for R2 in July because R2 required increased supervision. V14 stated that on 10/24/25 the facility implemented a doorway sensor for R2 as an audible alert to staff that they needed to assess R2's whereabouts immediately when that alarm sounds. V14 verified that the door sensor was not implemented on care plan.On 11/13/25 at 8:45 AM, V16, Physical Therapist (PT), stated that R1 is independent with ambulation with the walker. V16 stated prior to July of 2025, R1 was independent without the walker but due to decline especially with leg issues, R1 requires use of the walker for ambulation.On 11/13/25 at 9:57 AM, V10, Medical Doctor, stated that due to R1's age, medical diagnosis and increased weakness, R1 is at high risk for falls and without use of the walker R1 would most likely suffer fall with injury. Event ID: Facility ID: 145469 If continuation sheet Page 6 of 6