Inspection·December 17, 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 interview and record review the facility failed to ensure sufficient lighting in a resident's bedroom and failed to provide adequate supervision for a restless resident with dementia. These failures resulted in a fall for one (R6) of three residents reviewed for accidents, causing a brain bleed and skin tears to the right shoulder, right hand, and right forearm on the total sample list of 17.Findings include:The facility's Falls and Fall Risk Management Policy, dated March 2018, documents that based on previous evaluations and current data, staff will identify interventions related to a resident's specific risks and causes to prevent falls and to minimize complications from falls. The policy defines a fall as unintentionally coming to rest on the ground, floor, or other lower level, not as a result of an overwhelming external force.Fall risk factors identified in the policy include:Environmental factors: wet floors, poor lighting, incorrect bed height or width, obstacles in the footpath, improperly fitted or maintained wheelchairs, and unsafe or absent footwear;Resident conditions: fever, infection, delirium and other cognitive impairments, pain, lower extremity weakness, poor grip strength, medication side effects, orthostatic hypotension, functional impairments, visual deficits, and incontinence; andMedical factors: arthritis, heart failure, anemia, neurological disorders, and balance and gait disorders.The policy documents that staff are to use resident-centered approaches to managing falls and fall risk. These approaches include:Staff, with input from the attending physician, will implement a resident-centered fall prevention plan to reduce specific fall risk factors for each resident at risk or with a history of falls;A systematic evaluation of a resident's fall risk may identify several possible interventions, and staff may prioritize interventions (e.g., trying one or a few interventions at a time rather than many at once);Examples of initial approaches include exercise and balance training, rearranging room furniture, improving footwear, and adjusting lighting; andIn conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding for osteoporosis, as applicable) to minimize serious consequences of falling.The policy further documents that staff should monitor subsequent falls and fall risk by documenting each resident's response to interventions intended to reduce falls or fall risk. If interventions are successful in preventing falls, staff are to continue those interventions.R6's Minimum Data Set (MDS) dated [DATE] documents diagnoses of non-Alzheimer's dementia with behavioral disturbances and severe cognitive impairment. The MDS also documents that R6 had post-traumatic stress disorder (PTSD).R6's Care Plan, initiated on 7/27/25, documents a history of falls related to decreased safety awareness and includes an intervention dated 7/29/25 for staff to walk with R6 when he exhibited signs of restlessness.R6's Care Plan, initiated on 6/11/25, documents a history of falls related to medications (psychotropic, diuretic, cardiovascular, and pain medications) and unspecified medical factors. This Care Plan included an intervention to provide adequate lighting.R6's Fall Risk Evaluation dated 9/7/25 documents that R6 was at high risk for falls.R6's Electronic Medical Record (EMR) contains a nursing note dated 11/13/25 documenting that R6 was periodically attempting to stand and walk independently throughout the night. The note documents that staff successfully implemented the Care Plan intervention by walking alongside R6 using a walker and gait belt until R6 became tired and requested to go to bed.R6's Incident Investigation Report documents that R6 was found on the floor in his bedroom on 11/16/25 at 4:17 AM. The report documents that R6 sustained a fall with physical harm, including a hematoma to the right side of his head above the eye, two skin tears to the right shoulder, a skin tear to the right hand, and a skin tear to the left forearm.On 12/16/25 at 12:33 PM, V20, Certified Nursing Assistant (CNA), stated that R6 had been up all night on 11/16/25 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145469 If continuation sheet Page 2 of 4 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 12/17/2025 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 the nurses' station due to agitation, restlessness, and attempts to hit staff and other residents. V20 stated R6 appeared busy that night and, in her professional opinion, R6 should not have been put to bed at that time because he repeatedly stood up and sat down. V20 stated she was an agency CNA and that suggesting R6 remain up would not have been well received by facility staff. V20 further stated that at approximately 4:30 AM, while sitting at the nurses' station, she heard a thud and went to R6's room, where she found the lights off and R6 lying on the floor at the end of his bed with blood coming from his head. V20 stated the television was hanging off the wall, with cords wrapped around R6's leg.On 12/16/25 at 2:36 PM, V19, CNA, stated that R6 was restless and repeatedly attempting to get up and down from his wheelchair the night of the fall. V19 stated she put R6 to bed and that the bedroom lights were off. V19 stated that V20 called for help at approximately 4:00 AM, reporting that R6 had fallen. V19 stated she entered the room and found R6 lying on his back on the floor with blood on his head and on the floor, and that R6's left foot was tangled in the television cords.On 12/16/25 at 10:04 AM, V14, Licensed Practical Nurse (LPN), stated she was the nurse caring for R6 on the night of the unwitnessed fall on 11/16/25. V14 stated that R6 was at high risk for falls, had fallen several times the prior week, and had been moved to the secured dementia unit for closer monitoring. V14 stated R6 was sitting with staff at the nurses' station around 2:30 AM due to restlessness, fidgeting, and attempts to get out of his wheelchair. V14 stated that V19 and V20, CNAs, toileted R6 and put him to bed. V14 stated that at approximately 4:30 AM, V19 notified her that R6 had been found on the floor in his room and was bleeding from his head and arms.On 12/17/25 at 9:29 AM, V2, Regional Nurse Consultant (RNC), stated that if it had been her decision, she would not have discontinued the ten-minute safety checks when R6 was transferred to the dementia unit one week prior. V2 further stated that staff on the dementia unit may lack the necessary knowledge to properly care for residents with dementia.On 12/17/25 at 12:36 PM, V26, [NAME] County Coroner, confirmed that R6's cause of death was determined to be complications from an unwitnessed fall, resulting in bleeding in the space around the brain (subdural hematoma). Event ID: Facility ID: 145469 If continuation sheet Page 3 of 4 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 12/17/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on interview and record review, the facility failed to ensure consistent monitoring and documentation of bowel movements for residents requiring bowel management, resulting in constipation for one resident (R4) of three residents reviewed for bowel management in the sample list of 17. Findings include:R4's undated diagnosis list documents diagnoses of constipation; hemiplegia and hemiparesis following cerebral infarction affecting the left nondominant side; unspecified disorder of muscle; and difficulty walking.R4's Physician Orders, active as of 12/16/25, document an order for ferrous sulfate 325 mg (milligrams) oral tablet, one tablet by mouth daily.R4's Bowel Movement (BM) Task Sheet dated 11/17/25 through 11/24/25 documents the following: 11/17/25 - none 11/19/25 - none 11/20/25 - not applicable 11/21/25 - none 11/24/25 - none at 11:51 AM and not applicable at 12:42 AMNo bowel movements were documented on 11/18/25, 11/22/25, or 11/23/25.There are no Nursing Progress Notes in R4's medical record dated 11/25/25 documenting that V9, Licensed Practical Nurse (LPN), completed any type of bowel assessment for R4 on that date.On 12/16/25 at 11:45 AM, R4 stated that on 11/25/25 he complained of stomach pain to V8, Certified Nursing Assistant (CNA), multiple times and asked V8 to notify V9, LPN, early in the morning at approximately 6:00 AM. R4 stated that V9, LPN, did not enter his room until approximately 8:15 AM.On 12/16/25 at 1:42 PM, V10, Medical Director, stated that if a resident has constipation, symptoms of constipation, or no bowel movement for two to five days (depending on the resident's normal pattern), staff should notify the medical doctor (MD) for further instructions. V10 stated that the nurse should have assessed the resident after R4 complained of abdominal pain.On 12/17/25 at 11:45 AM, V2, Regional Nurse Consultant, stated that staff should report when a resident has not had a bowel movement for three days and that the floor nurse or clinical manager should review daily clinical alerts for residents without a bowel movement for three days.The facility's Bowel Management Program dated 12/17/25 documents that CNAs are to promptly document bowel movements in the medical record; the floor nurse or clinical manager is to review daily clinical alerts to monitor residents who have not had a bowel movement in three days; and the floor nurse or clinical manager is to notify the MD as needed for further orders related to no bowel movement for three days. Event ID: Facility ID: 145469 If continuation sheet Page 4 of 4