The Haven of Paris: Fall Monitoring Failure - IL
The resident, identified in inspection records only as R1, is oriented to person only and frequently gets up without calling for help. Staff knew this. A certified nursing assistant told inspectors on October 28 that R1 gets up on his own to get coffee, and that is exactly how he fell the first time, on August 30. He fell again on October 18 at 3:50 PM. His electronic medical record shows he was last repositioned at 8:22 that morning, more than seven hours earlier.
The facility's own Assistant Director of Nursing told inspectors that residents at high fall risk should be checked every 15 minutes, that CNAs are responsible for documenting those checks in the electronic record, and that staff should have been checking R1 at minimum every two hours. She could not produce documentation showing any of those checks had been done on October 18.
The Director of Nursing confirmed the same thing. On October 27, she told inspectors that high fall risk residents should be checked every 15 minutes and that this requirement belongs on the care plan. Then she confirmed that staff were not checking R1 every 15 minutes, even though he was a high fall risk.
A separate staff member explained that 15-minute checks are reserved for residents at risk for wandering or elopement. R1 was not flagged for elopement. He was flagged for falls. The distinction, in practice, left him without the monitoring his own care plan required.
The inspection was conducted as a complaint investigation on October 28, 2025. Inspectors cited the lapse as causing actual harm to one of a few residents affected.
R1 had already shown staff exactly what he would do when left alone. He had done it in August. He did it again in October.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Haven of Paris from 2025-10-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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 23, 2026 · Our methodology
The Haven of Paris in PARIS, IL was cited for violations during a health inspection on October 28, 2025.
The resident, identified in inspection records only as R1, is oriented to person only and frequently gets up without calling for help.
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.