The Haven of Paris: Abuse Report Failures - IL
The incident had happened more than two months earlier.
On June 18, 2025, a staff member responded to an alarm sounding in a room across the hall and found a female resident, identified in inspection records as R4, standing from her wheelchair and grasping another female resident, R6, by both wrists. Staff separated the two women immediately. The facility notified R4's healthcare power of attorney, the primary care provider, and the interdisciplinary team. The ombudsman and R4's power of attorney were documented as notified in the abuse investigation report.
What the facility did not do was tell the state.
By the time surveyors arrived on August 22, the administrator, identified in inspection records as V1, had produced not one but three separate written investigation reports, all dated June 18, 2025, all purporting to document the same event. Each was different.
The first report, V1 told the surveyor, incorrectly identified the residents involved. It named R5 and R4, not R4 and R6. V1 said she had fixed that and given the corrected version to the surveyor the day before the inspection concluded. The third report, provided to the surveyor at 9:25 that morning, was the first one to include what a nursing note had documented on the day of the incident itself: that R4 had grabbed R6's wrist. V1 told the surveyor that detail "should have been in the investigation report to begin with."
Three reports. Two months. One admission that the state still hadn't been told.
The nursing note from June 18 is precise about what happened. Written at 2:46 in the afternoon, it describes a staff member responding to an alarm and observing a resident "standing from W/C and grasping another female resident by both wrists." Staff separated the residents and notified the appropriate supervisor and abuse coordinator. A call was placed to R4's healthcare power of attorney, who said she understood, expressed appreciation for the call, and explained she wouldn't be coming to visit that day because of inclement weather but planned to come the next day. She had no concerns or other questions.
The note is thorough in what it covers. It documents the alarm, the observation, the separation, the notifications up the chain, and the family's response. It does not indicate that anyone contacted the Illinois Department of Public Health.
That gap, between what was documented internally and what was reported externally, is what the inspection found.
V1, who held the dual role of administrator and abuse prevention coordinator, told the surveyor during the 8:40 a.m. interview that the investigation was into the altercation between R4 and R6, and that she had not sent an updated report to IDPH. The surveyor's notes record her saying she "should probably do that" as though the thought had only just occurred to her, ten weeks after the incident.
A licensed practical nurse, identified as V12, conducted a skin assessment on R6 following the incident and found no injury. That finding is documented. What is not documented, in any of the three investigation reports produced during the survey, is a complete and accurate account of what happened, filed with state regulators within the timeframe the facility's own abuse policy contemplates.
That policy, dated January 9, 2024, states that the facility affirms the right of residents to be free from abuse and prohibits mistreatment in any form. It describes the facility as having "attempted to establish a resident sensitive and resident secure environment."
The three investigation reports tell a different story about how that environment functions in practice, not in the moment of the incident, where staff responded quickly and separated the residents, but in the weeks that followed, when the paperwork multiplied and the state was never called.
R6 is described in the nursing note as a resident whose alarm had sounded in her room. She was grabbed by both wrists by another resident. A nurse checked her skin. No injury was found. The ombudsman was notified. Her family, or whoever holds her power of attorney, was listed as notified in the investigation report.
What R6 was not, for more than two months, was the subject of an accurate report to the agency responsible for overseeing her care.
The inspection that caught this was a complaint survey, meaning someone had raised a concern that prompted regulators to come. The survey was completed on August 22, 2025, the same morning V1 produced the third version of the investigation report and acknowledged, in the same breath, that none of the versions had gone to IDPH.
The deficiency was cited at a harm level of minimal harm or potential for actual harm, a designation that reflects where the agency placed the incident on its severity scale. It does not mean nothing happened. R4 grabbed R6 by both wrists. That is what the nursing note says. That is what the third investigation report, the one that took two months and two prior drafts to produce, finally acknowledged.
The facility's abuse policy runs to several sentences about freedom from corporal punishment, involuntary seclusion, and physical restraint. It says the facility prohibits mistreatment and has attempted to create a secure environment. The word "attempted" is doing more work than the policy's authors likely intended.
V1 said she would probably send the updated report to IDPH. The surveyor's notes do not record whether she had done so by the time the inspection closed that afternoon.
R6 sat in her wheelchair in a room at The Haven of Paris while two months passed and three reports were written, each one a little more accurate than the last, none of them sent to the state.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Haven of Paris from 2025-08-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 2, 2026 · Our methodology
The Haven of Paris in PARIS, IL was cited for abuse-related violations during a health inspection on August 22, 2025.
The incident had happened more than two months earlier.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.