The Haven of Paris: Fall Monitoring Failure Harms Resident - IL
In the seven and a half hours in between, staff at The Haven of Paris left a dementia patient with a known history of getting up on his own, unmonitored, despite their own protocols requiring someone lay eyes on him every 15 minutes.
The resident, identified in inspection records only as R1, had dementia and was alert and oriented to person only, meaning he could recognize faces but little else about his surroundings. He had already fallen once before, on August 30, under similar circumstances. A certified nursing assistant told inspectors he got up that first time to get coffee. Nobody changed what happened after that.
On October 18, a CNA stationed at the nurses' station looked up and saw R1 coming out of a neighboring resident's room. Then he lost his balance and fell. She told inspectors she didn't know what time the fall happened or the last time she had seen him. "I don't have anything else to tell you," she said.
The registered nurse caring for R1 that day told inspectors she knew exactly what he was like. He had dementia, she said. He was alert to person only. He frequently got up on his own without calling for help. She said the CNAs should have been checking on him every two hours, "if not more frequently."
More frequently meant every 15 minutes. That was the standard the facility's own staff described to inspectors for residents at high fall risk or high elopement risk. The LPN who served as MDS Coordinator explained that 15-minute checks, which the facility called "increased visuals," were the protocol for residents determined to wander or at risk of leaving on their own. The Director of Nursing confirmed it: high fall-risk residents should be checked every 15 minutes, and it should be on the care plan.
It was on the care plan. Staff just weren't doing it.
The Assistant Director of Nursing told inspectors that CNAs are responsible for checking high-risk residents every two hours at minimum, and that those checks are supposed to be logged as a task in the electronic medical record. She said residents at high fall or elopement risk should be seen every 15 minutes. Then she looked for documentation showing R1 had been checked on October 18. She could not find any.
The Director of Nursing confirmed to inspectors on October 27 that staff were not checking on R1 every 15 minutes, even though he was flagged as a high fall risk.
What the records show is a single entry: repositioned at 8:22 AM. Then nothing until the fall note at 3:50 PM.
Federal inspectors cited the facility under F0689, the tag covering protection from accident hazards, and classified the violation as causing actual harm to a resident. The inspection was conducted October 27 and 28, 2025, following a complaint.
R1 had already shown staff exactly what he would do when left alone. He got up for coffee. He wandered into neighboring rooms. He moved without calling anyone. Every person interviewed by inspectors knew this about him. The nurse knew it. The CNAs knew it. The assistant director of nursing knew the checks were supposed to happen and knew they should be documented. The director of nursing knew the 15-minute standard applied to him specifically.
The gap between what everyone knew and what anyone did stretched across seven and a half hours on October 18, and ended with a man with dementia on the floor of a hallway, coming out of someone else's room.
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.
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: June 23, 2026 · Our methodology
The Haven of Paris in PARIS, IL was cited for violations during a health inspection on October 28, 2025.
He had already fallen once before, on August 30, under similar circumstances.
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.