Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stillhouse Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility failed to submit complete and accurate RN hours to CMS for the first quarter of fiscal year 2024. The DON worked on several dates, but her hours were not recorded due to the lack of a manual input process, leading to the deficiency in the staffing report.
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to unmet care needs and potential risks. Critical details such as the use of grab bars, anticoagulant medication, and PTSD interventions were missing from the care plans, highlighting communication gaps and inadequate documentation.
The facility had a medication error rate of 17.95%, with delays in administering medications to three residents due to high workload and staff covering multiple halls. The errors involved late administration of medications for seizures, low blood pressure, thyroid disease, pain, and gastroesophageal disease.
The facility failed to ensure timely medication administration for three residents, leading to significant delays in receiving seizure, blood pressure, anticoagulant, and pain medications. Staff cited workload and managing multiple halls as reasons for the delays.
A resident with Alzheimer's disease and malnutrition was not provided necessary assistance with eating during a lunch meal, leading to inadequate food intake. Staff failed to offer substitutes, health shakes, or supplements, despite the resident's care plan indicating the need for such assistance. The DON and Administrator acknowledged the oversight, but no policies for therapeutic diets or ADLs for eating were provided.
A facility failed to follow its smoking policy for a resident with Paranoid Schizophrenia and Dementia, who was observed smoking without a required smoking apron. Staff members acknowledged the oversight, which placed the resident at risk of burns.
A facility failed to ensure a resident's urinary catheter was properly secured, risking damage and infections. The resident, with severe cognitive impairment and multiple diagnoses, was observed without a catheter strap, and staff confirmed the responsibility to secure it. Records indicated an order for securing the catheter, but it was not followed.
The facility failed to obtain informed consent and properly assess the use of bed rails for two residents, leading to potential safety risks. Observations and interviews revealed that the residents did not use the grab bars as intended, and staff lacked understanding of the need for informed consent and proper assessment.
The facility failed to establish a detailed system for the receipt and disposition of controlled drugs, leading to a lack of accurate reconciliation. Several controlled medications were stored without a log, and the DON was the only one with access. The Administrator acknowledged the issue, and the facility's policy requires safeguarding and accurate documentation of controlled drugs.
The facility failed to monitor a resident for side effects while taking Xarelto and another resident for edema while on furosemide. Staff interviews revealed inconsistencies and a lack of clarity regarding responsibilities for monitoring side effects and adverse reactions.
The facility failed to provide a health shake with lunch as ordered by the physician for a resident with Alzheimer's and protein-calorie malnutrition. Staff did not offer a substitute or assist the resident with eating, despite the resident's known difficulty with vision and recent poor appetite. Interviews revealed that staff did not follow the protocol for offering supplements when a resident consumed less than 50% of a meal.
Failure to Submit Complete RN Hours to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for the first quarter of fiscal year 2024. Specifically, the facility did not transmit RN hours for several dates in November and December 2023. The missing dates were 11/18, 11/19, 12/02, 12/03, 12/16, 12/17, and 12/30. The Director of Nursing (DON) worked on these dates, but her hours were not recorded because she does not clock in, and the hours must be manually inputted. This manual input process was not completed before the submission to CMS, leading to the deficiency in the staffing report. The HR manager confirmed that the payroll system automatically transmits hours to CMS, but the DON's hours were not captured due to the lack of a manual input process. The Administrator acknowledged that the DON was present on the specified dates but forgot to log her hours, and there was no existing policy for payroll-based journal submissions. During interviews, the HR manager and the Administrator both indicated that the failure to submit the RN hours was due to the DON not clocking in and the absence of a manual input process for her hours. The HR manager stated that the computerized payroll system automatically transmits hours to CMS, but since the DON does not use the time clock, her hours were not included in the submission. The Administrator confirmed that the DON worked numerous hours on the specified dates but did not log them, resulting in the omission. There was no policy in place to ensure the manual input of the DON's hours into the payroll-based journal, leading to the incomplete submission to CMS.
Failure to Develop Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for three residents, leading to unmet care needs and potential risks. For Resident #63, the care plan did not include the use of a grab bar, despite the resident's need for substantial assistance with various tasks. Observations showed that the grab bar was not used during care, and staff were unaware of its necessity due to the lack of documentation in the care plan. Interviews with staff revealed that they relied on verbal instructions rather than the care plan, highlighting a communication gap in the facility's procedures. Resident #25's care plan did not address his use of anticoagulant medication or the need for assist/grab bars. Despite the resident's moderate cognitive impairment and reliance on grab bars for mobility, these critical details were missing from the care plan. Interviews with staff, including the LVN, ADON, and DON, confirmed that the anticoagulant medication and grab bars should have been included in the care plan to ensure proper monitoring and safety. The lack of documentation posed a risk of internal bleeding and other complications, as new staff would be unaware of these essential aspects of the resident's care. For Resident #42, the care plan failed to include person-centered interventions for his PTSD, specifically his lack of triggers and unwillingness to discuss his trauma history. Despite the resident's clear communication abilities and moderate cognitive impairment, the care plan did not reflect his mental health needs. Interviews with the DON, Social Worker, and other staff revealed that there was no policy for trauma-informed care, and staff were not adequately informed about the resident's PTSD. This oversight could lead to re-traumatization and inadequate care for the resident's mental health needs.
Medication Administration Delays
Penalty
Summary
The facility failed to ensure that it was free of a medication error rate of 5 percent or greater, resulting in a medication error rate of 17.95%. This was based on 7 errors out of 39 opportunities, involving three residents. The errors included the late administration of Levetiracetam for a resident with seizures, Midodrine, Eliquis, and Levothyroxine for a resident with low blood pressure and severe cognitive impairment, and Tramadol, Levothyroxine, and Protonix for a resident with arthritis and no cognitive deficits. These delays in medication administration were observed and confirmed through record reviews and staff interviews. One resident, who was moderately cognitively impaired, was supposed to receive Levetiracetam at 7:00 a.m. but received it at 8:25 a.m. Another resident with severe cognitive impairment and multiple diagnoses, including low blood pressure and thyroid disorder, was supposed to receive Midodrine at 6:00 a.m. but received it at 8:40 a.m., along with other medications that were also administered late. A third resident, who had no cognitive deficits but suffered from arthritis and gastroesophageal disease, received Tramadol, Levothyroxine, and Protonix late, with the Tramadol being administered almost two hours past the scheduled time. Interviews with the staff, including LVN A and MA B, revealed that the delays were due to the high workload and the need to cover multiple halls, making it difficult to adhere to the one-hour before and one-hour after medication administration window. The Director of Nursing (DON) acknowledged the issue and mentioned that the computerized system does provide a late administration report, which she is responsible for monitoring. However, the late administration of medications could potentially cause adverse effects on the residents' treatment regimens, as noted by the DON and the Administrator.
Failure to Ensure Timely Medication Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting three residents. Resident #172, an elderly female with moderately impaired cognition, did not receive her seizure medication, Levetiracetam, at the scheduled time. The medication was administered at 8:25 a.m. instead of the prescribed 7:00 a.m., which could have led to a risk of seizures. The comprehensive care plan for Resident #172 indicated the need for timely administration of anticonvulsants, but this was not adhered to by LVN A, who cited workload as the reason for the delay. Resident #66, a severely cognitively impaired elderly female with low blood pressure and deep vein thrombosis, also experienced delays in medication administration. Her Midodrine and Eliquis were scheduled for 6:00 a.m. and 6:30 a.m., respectively, but were administered at 8:40 a.m. The comprehensive care plan for Resident #66 included monitoring for symptoms related to her cardiovascular status and anticoagulant therapy, but it did not specifically address the timely administration of these medications. LVN A admitted to being late due to managing two halls, which resulted in the delay. Resident #17, an elderly female with arthritis and no cognitive deficits, received her pain medication, Tramadol, late. The medication was scheduled for 6:00 a.m. but was administered at 7:49 a.m. The comprehensive care plan for Resident #17 included administering analgesics as ordered, but this was not followed. MA B, responsible for administering the medication, cited workload and the number of residents as reasons for the delay. Both the Administrator and the DON acknowledged the importance of timely medication administration and the potential negative impact of delays on residents' treatment regimens.
Failure to Assist Resident with Eating
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary assistance with eating during a lunch meal. Resident #16, a [AGE] year-old female with Alzheimer's disease and unspecified protein-calorie malnutrition, was observed struggling to eat her meal on 03/25/2024. She was using a fork for soupy meat, which was falling off, and had trouble biting her roll. She consumed less than 25% of her food and did not receive her health shake. Staff did not offer a substitute, health shake, or supplement, nor did they assist her with eating during the meal observation period. This lack of assistance was contrary to her care plan, which indicated she required supervision or touching assistance while eating and had a history of weight loss and malnutrition risk. Interviews with staff confirmed that they were aware of the resident's needs and the importance of providing assistance and health shakes, but these actions were not taken during the observed meal. The Director of Nursing (DON) and the Administrator both acknowledged that the staff should have provided the necessary assistance and health shakes to prevent further weight loss. The facility did not provide a policy for therapeutic diets or ADLs for eating upon request. The DON and Administrator stated that the nurse in the dining room was responsible for monitoring and ensuring assistance was provided, but this did not occur during the observed meal. The failure to assist Resident #16 with eating and provide her health shakes as ordered could contribute to further weight loss and a decline in her overall health.
Failure to Follow Smoking Policy for Resident
Penalty
Summary
The facility failed to follow their established smoking policy for a resident with a history of Paranoid Schizophrenia, Dementia, and coordination issues. The resident was observed smoking without a required smoking apron, which was mandated by her care plan and smoking assessment due to her shaking and tremors. During the observation, a housekeeper lit a cigarette and handed it to the resident without ensuring she had the smoking apron on, which was later retrieved by a CNA. Interviews with staff members, including a CNA, LVN, housekeeper, DON, and the Administrator, confirmed that it was the responsibility of the staff member accompanying the resident to ensure the smoking apron was worn to prevent potential burns. The deficiency was identified during an observation where the resident was seen smoking without the apron, and staff members acknowledged the oversight. The facility's policy required residents to be reassessed for their ability to smoke safely, and the resident's care plan specifically indicated the need for a smoking apron. Despite this, the staff failed to adhere to the policy, placing the resident at risk of burns from dropped cigarettes or ashes. The DON and Administrator acknowledged the importance of the smoking apron and the potential harm from not using it, indicating a lapse in following established safety protocols.
Failure to Secure Urinary Catheter
Penalty
Summary
The facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections. Specifically, the facility did not properly secure Resident #2's urinary (foley) catheter to his leg, which could lead to damage to the bladder, penis, or urethra, dislodging of the catheter, and urinary tract infections. Resident #2, a male with severe cognitive impairment and multiple diagnoses including hemiplegia and vascular dementia, was observed without a catheter strap in place, and his catheter tubing was not anchored to his leg or the linens. This observation was confirmed by CNA C, who stated that the nurses were responsible for ensuring the catheter was properly secured. LVN E and the DON also confirmed that it was the nurse's responsibility to secure the catheter tubing and acknowledged the potential harm if the catheter was not properly secured. The facility's records indicated that Resident #2 had an order to ensure the catheter strap was in place and holding every shift change. However, during an observation, it was found that the catheter tubing was not secured. Interviews with the CNA, LVN, DON, and Administrator revealed that the catheter should have been secured to prevent it from being pulled out, which could cause pain or discomfort. The Administrator mentioned that if the resident had requested not to wear a leg strap, it should have been documented in the care plan, but otherwise, the catheter should have been properly secured. The facility's policy on indwelling urinary catheter care also indicated the need to secure the tubing to prevent migration, friction, or tension of the catheter.
Failure to Obtain Informed Consent and Properly Assess Bed Rail Use
Penalty
Summary
The facility failed to ensure informed consent for the use of bed rails for two residents, leading to potential safety risks. For Resident #63, the facility did not obtain informed consent prior to the installation of bed rails, despite the resident's bed rail assessment not recommending their use. Additionally, the facility did not document any attempts to use alternatives before installing the bed rails. Observations and interviews revealed that Resident #63 did not use the grab bar and had sustained bruising and petechiae on her forehead from leaning against it, indicating improper use and maintenance of the bed rail. For Resident #25, the facility also failed to document attempts to use alternatives before installing bed rails and did not obtain informed consent prior to their installation. The resident's bed rail safety evaluation initially recommended the use of bed rails but later indicated that bed rails were not recommended. Despite this, the resident continued to have grab bars installed on his bed. Interviews with staff revealed a lack of understanding regarding the need for informed consent and proper assessment for the use of bed rails. The facility's policy on bed rails required attempts to use alternatives and obtaining informed consent before installation, which was not followed in these cases. The failure to adhere to these policies and procedures could place residents at risk for entrapment and serious injury. The observations, interviews, and record reviews highlighted significant lapses in the facility's compliance with safety protocols for bed rail use.
Failure to Maintain Accurate Log for Controlled Medications Awaiting Disposal
Penalty
Summary
The facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation. During an observation and interview, it was found that several controlled medications were stored in a locked cabinet without a medication log for those awaiting disposal. The medications included Clonazepam, Tramadol, Alprazolam, and Oxycodone. The Director of Nursing (DON) stated that she was the only one with the key to the cabinet and that she reconciled the medications with a nurse before storing them. However, there was no log maintained for these medications until their destruction with the pharmacist, which occurred monthly. This lack of logging could lead to an inability to account for the medications accurately and potentially result in loss or diversion of the drugs. The facility's policy on controlled medications, revised in January 2022, requires safeguarding access and storage of controlled drugs and maintaining a process for monitoring, administration, documentation, reconciliation, and destruction. The Administrator acknowledged that without accurate reconciliation, there was no way to account for the narcotics properly. The facility's medication destruction binder indicated that narcotics were destroyed monthly with the pharmacist and two witnesses, but the absence of a log for stored narcotics awaiting destruction was a significant oversight. This deficiency was identified during a survey and was based on observation, interview, and record review.
Failure to Monitor Drug Regimen for Side Effects
Penalty
Summary
The facility failed to ensure that Resident #25's drug regimen was adequately monitored for side effects and adverse reactions while taking Xarelto, an anticoagulant medication. Despite the resident's medical history, which included hemiplegia, diabetes mellitus, atrial fibrillation, and heart failure, there was no indication in the care plan or medication administration record that the resident was being monitored for side effects such as abnormal bleeding. Interviews with the LVN, ADON, and DON revealed that the monitoring task was not set up, and there was confusion about who was responsible for ensuring this monitoring was in place. Similarly, the facility did not adequately monitor Resident #42's edema while the resident was taking furosemide, a diuretic medication. The resident's care plan included instructions to monitor for side effects and the effectiveness of the diuretic, but the medication administration record did not reflect any monitoring for edema. Interviews with the LVN and DON indicated that there was no routine monitoring for long-term diuretic use unless a new concern arose, which was contrary to the expectations stated by the Administrator. Both deficiencies highlight a lack of proper monitoring and documentation for residents on specific medications, which could lead to significant health risks. The staff interviews revealed inconsistencies and a lack of clarity regarding the responsibilities for monitoring side effects and adverse reactions, contributing to the oversight in both cases.
Failure to Provide Ordered Health Shake
Penalty
Summary
The facility failed to ensure food was prepared in a form designed to meet individual needs for a resident reviewed for nutrition. Specifically, the facility did not provide a health shake with the lunch meal as ordered by the physician for a resident with Alzheimer's disease and protein-calorie malnutrition. The resident had a history of unplanned weight loss and was on a mechanically altered diet. Observations revealed that the resident did not receive the health shake during lunch, and staff did not offer a substitute or assist the resident with eating, despite the resident's known difficulty with vision and recent poor appetite. Interviews with staff indicated that when a resident consumed less than 50% of a meal, they were supposed to notify the nurse and offer a supplement or health shake. However, this protocol was not followed for the resident in question. The Director of Nursing (DON) and the Administrator both acknowledged the importance of ensuring the resident received assistance and the ordered health shakes to prevent further weight loss. The DON also noted that there was no policy for therapeutic diets in place at the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Paris
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Paris | 0.6 mi | ★★★★★ | 5 | 0 |
| Brentwood Terrace Healthcare And Rehabilitation | 0.6 mi | ★★★★★ | 3 | 0 |
| Legend Healthcare And Rehabilitation - Paris | 2.3 mi | ★★★★★ | 14 | 0 |
| Heritage House At Paris Rehab & Nursing | 2.9 mi | ★★★★★ | 13 | 0 |
| Homestead Of Hugo | 21.4 mi | ★★★★★ | 4 | 1 |
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