The Haven of Paris: Narcotic Records Gaps After Hip Fracture - IL
Federal inspectors cited The Haven of Paris following a complaint inspection completed October 16, 2025, finding that the facility failed to maintain complete and accurate medical records for a resident identified in the report only as R2.
R2 fell on September 16, 2025. Before the fall, she had received just four doses of Tramadol, a narcotic analgesic, over nearly five months, since the supply was dispensed from the pharmacy on April 25. After the fall, she received 18 doses in less than four weeks. Her physician's orders required pain assessments every shift, rated on a scale of one to ten.
Nurses signed off on those assessments. They just didn't fill them in.
The Medication Administration Records show nurses initialed the pain assessment fields across multiple shifts but left the actual numeric scores blank. The Director of Nursing reviewed the records on October 16 and confirmed the pattern. Nurses had been documenting that they completed the assessments without documenting what they found.
The narcotic discrepancy is more specific. On September 19 at 7:00 a.m., September 28 at 8:00 a.m. and 8:00 p.m., September 29 at 8:00 p.m., and October 9 at 8:00 p.m., Tramadol tablets were removed from the locked compartment on the medication cart and signed out on the narcotic count sheet. None of those administrations appear in R2's Medication Administration Record.
The Director of Nursing, identified in the report as V2, said she had reviewed the records the day before the inspection and spotted the gaps herself. "I confirmed with those nurses that it was given," she told inspectors. "They just forgot to document on the MAR."
She did not identify which nurses.
The MRI tells its own story. On October 10, 2025, R2 left the facility by ambulance for an MRI of her right hip at a local hospital. The scan was completed at 11:18 a.m. The results were unambiguous: an acute, impacted subcapital hip fracture with lateral displacement and extensive soft tissue edema, meaning broken bone fragments wedged tightly together, with significant swelling throughout the surrounding tissue.
Nothing in R2's medical record documents that she left the facility that day, or that she returned.
The last entry before the MRI was a Nurse Practitioner note from October 9 at 11:46 a.m. The next entry is a transfer note dated October 12 at 4:01 p.m., recording that R2 was sent by ambulance to the local community hospital due to abnormal MRI results. Two days of her medical record, including the entire MRI trip, simply do not exist in her chart.
The inspection covered three residents flagged for falls and medical record review. Inspectors found the documentation failures in one of the three.
V2 acknowledged each gap when inspectors walked her through the records on the morning of October 16. She confirmed the narcotic count sheet showed removals that the MAR didn't reflect. She confirmed nurses had initialed pain assessments without entering scores. She confirmed the MRI transport went unrecorded.
"I am new to the facility and new to the Director of Nursing position," she said. "This will be addressed. It is Nursing 101 to document accurately and completely in the resident's medical record."
What the records cannot now answer is what R2's pain levels actually were in the weeks after her fall. The nurses who removed Tramadol from the cart on those five occasions are not named in the report. Whether the doses were given to R2, or to someone else, or not given at all, the documentation does not establish.
R2 was transferred to an acute care hospital on October 12 with a fractured hip that had been diagnosed two days earlier and left unrecorded.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Haven of Paris from 2025-10-16 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 9, 2026 · Our methodology
The Haven of Paris in PARIS, IL was cited for violations during a health inspection on October 16, 2025.
After the fall, she received 18 doses in less than four weeks.
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.