Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Legend Healthcare And Rehabilitation - Paris during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment sustained second-degree burns after spilling hot coffee served by a CNA without a temperature check. The facility lacked a specific policy on hot liquid management, contributing to the incident. The coffee was brewed in the breakroom, bypassing the kitchen's temperature control procedures.
The facility failed to complete timely MDS assessments for two residents, with both assessments being finalized 3 days late. The MDS Coordinator Resource Nurse, who took over after the previous nurse went on leave, acknowledged the delay, citing the assessments were part of overdue tasks. The facility follows the RAI Manual guidelines, and the Administrator expects timely completion of assessments.
The facility failed to complete quarterly MDS assessments within the required time frame for four residents, including those with syncope, Alzheimer's, hypertension, and diabetes. The MDS Coordinator Resource Nurse, who assumed duties after the regular nurse went on leave, acknowledged the late completions. The facility followed RAI Manual guidelines but lacked a specific policy for MDS assessments.
A facility failed to provide scheduled hygiene care to three residents, resulting in missed baths and inadequate personal hygiene. One resident with diabetes and pressure ulcers reported strong body odor and unshaven facial hair, while another with Alzheimer's disease received fewer baths than scheduled, affecting her mood. A third resident with cognitive impairment felt unclean due to infrequent bathing. Interviews revealed challenges in completing scheduled baths and lack of documentation for refusals.
A facility failed to ensure a resident's drug regimen was free from unnecessary medications by administering Humulin R insulin without a documented diagnosis of diabetes mellitus. Despite the resident's medical records lacking this diagnosis, insulin was prescribed and administered. Interviews with staff revealed a lack of responsibility and clarity in verifying diagnoses and medication orders, leading to this oversight. The facility's policy requires medications to align with the resident's service plan, which was not adhered to in this case.
The facility failed to attempt gradual dose reductions or document contraindications for three residents on psychotropic medications. A resident with severe cognitive impairment was on Risperdal without GDR attempts. Another resident with paranoid personality disorder continued Risperdal despite a failed GDR attempt. A third resident received Ativan and Risperidone without appropriate diagnoses, and the Ativan lacked a 14-day stop date, risking unnecessary medication use.
A facility failed to maintain an effective infection control program when an LVN did not perform hand hygiene after taking a blood sugar reading from a resident with diabetes, congestive heart failure, and Alzheimer's. Despite the facility's policies requiring hand hygiene before and after resident contact, the LVN admitted to not washing hands, which staff agreed could lead to infection risks.
A resident treated for a urinary tract infection with Ciprofloxacin was not included in the facility's Tracking and Trending Log for antibiotic use, as required by the antibiotic stewardship program. Despite the resident's treatment being administered as ordered, the oversight was acknowledged by the Infection Preventionist, who noted the potential impact on monitoring accuracy and staff training. The DON and Administrator expected the resident to be monitored, indicating a lapse in following established procedures.
Resident Burned by Hot Coffee Due to Lack of Temperature Check
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents and injury from hot liquid spills for a resident. The incident involved a resident who sustained a thermal burn from spilling hot coffee on her leg. The coffee was served by a CNA without checking the temperature of the liquid, which was against the facility's policy of not serving liquids above 140 degrees. The resident, who had moderate cognitive impairment and required supervision for eating, was able to manage hot liquids independently according to her assessment. However, on the day of the incident, the CNA brewed coffee in the employee breakroom and served it to the resident without verifying the temperature. The resident spilled the coffee while adding sugar and creamer, resulting in second-degree burns on her thigh. Interviews with staff revealed that the facility did not have a specific policy on hot liquid management or accidents and hazards related to hot liquid spills. The DON was unaware of the incident until after it occurred, and the ADM acknowledged the lack of a policy addressing such incidents. The facility's oversight in ensuring that all hot liquids were served at a safe temperature and the absence of a comprehensive policy contributed to the deficiency.
Delayed MDS Assessments for Two Residents
Penalty
Summary
The facility failed to conduct timely and comprehensive assessments for two residents, leading to deficiencies in identifying and meeting their needs. Resident #13's Annual Minimum Data Set (MDS) assessment was not completed within the required 14 days of admission, being finalized 3 days late. Similarly, Resident #28's Admission MDS assessment was also completed 3 days past the required timeframe. These delays in completing the MDS assessments could potentially place residents at risk of not having their needs properly identified and addressed. The MDS Coordinator Resource Nurse, who assumed the role after the previous MDS nurse went on maternity leave, acknowledged the delay in completing the assessments. The nurse admitted that the assessments were part of the end-of-month tasks that were either due or overdue when she took over. Despite the absence of a specific facility policy on MDS assessments, the facility followed the Resident Assessment Instrument (RAI) Manual guidelines. The Administrator expressed an expectation for timely completion of MDS assessments according to facility policies.
Late Completion of MDS Assessments
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required time frame for four residents. Resident #9, a [AGE]-year-old with syncope and collapse, had an MDS assessment with an Assessment Reference Date (ARD) of 10/23/24, which was completed 3 days late. Resident #16, a [AGE]-year-old with Alzheimer's, had an MDS assessment with an ARD of 10/18/24, completed 3 days late. Resident #26, a [AGE]-year-old with hypertension, had an MDS assessment with an ARD of 10/16/24, completed 5 days late. Resident #31, a [AGE]-year-old with diabetes, had an MDS assessment with an ARD of 10/17/24, completed 4 days late. The MDS Coordinator Resource Nurse, who took over the duties on 10/22/24, acknowledged the late completion of assessments, attributing it to the transition period after the regular MDS nurse went on maternity leave. The facility did not have a specific policy related to MDS assessments but followed the Resident Assessment Instrument (RAI) Manual guidelines. The Administrator expected timely completion of MDS assessments per facility policies. The RAI guidelines require that the MDS completion date must be no later than 14 days after the ARD.
Failure to Provide Scheduled Hygiene Care
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) received necessary services to maintain personal hygiene. This deficiency was observed in three residents who did not receive scheduled showers or bed baths at least three times per week. The lack of proper hygiene care was evident in the residents' conditions and their reports of missed bathing schedules. Resident #173, a female with diabetes mellitus type II, COPD, and stage III pressure ulcer, required maximal assistance for personal hygiene. Despite her needs, she missed several scheduled baths over a two-month period. During an interview, she expressed dissatisfaction with her hygiene care, noting a strong body odor and unshaven facial hair. She stated that she never refused baths and emphasized the importance of hygiene for her skin healing and personal dignity. Resident #16, diagnosed with Alzheimer's disease and blindness, also required maximal assistance for bathing. She reported receiving fewer baths than scheduled, which affected her mood and sense of cleanliness. Similarly, Resident #61, with moderate cognitive impairment and incontinence issues, received inadequate bathing assistance, leading her to feel unclean and embarrassed. Interviews with CNAs and the DON revealed challenges in completing all scheduled baths, with some residents' refusals not being documented or communicated to families.
Failure to Document Necessary Diagnosis for Insulin Administration
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically regarding the administration of Humulin R insulin. The resident, a 76-year-old male, was admitted with diagnoses including malignant neoplasm of the colon, hypothyroidism, and unspecified protein-calorie malnutrition. However, there was no documented diagnosis of diabetes mellitus, which is necessary to justify the use of Humulin R insulin. Despite the absence of this diagnosis in the resident's face sheet, quarterly MDS assessment, and hospital history, the resident was receiving insulin treatment. Interviews with facility staff revealed a lack of clarity and responsibility in ensuring that the resident's medical records accurately reflected the necessary diagnoses for prescribed medications. The Director of Nursing (DON) acknowledged that the resident came from the hospital with insulin orders but without a diabetes diagnosis. The Medical Doctor (MD) admitted to only glancing over hospital orders and assumed the hospital should have provided the diagnosis. Various staff members, including the Assistant Directors of Nursing (ADONs), Registered Nurses (RNs), and Licensed Vocational Nurses (LVNs), described a process where multiple individuals were responsible for entering and verifying diagnoses and medication orders, but there was a breakdown in ensuring the accuracy of these records. The deficiency was further highlighted by the facility's policy on medication administration, which requires medications to be given in accordance with the resident's service plan. The lack of a documented diabetes diagnosis for the resident receiving Humulin R insulin indicates a failure to adhere to this policy, potentially placing the resident at risk for adverse drug reactions and unnecessary medication use.
Failure to Implement Gradual Dose Reductions and Appropriate Diagnoses for Psychotropic Medications
Penalty
Summary
The facility failed to ensure a gradual dose reduction (GDR) was attempted or documented contraindications for three residents receiving psychotropic medications. Resident #1, a female with severe cognitive impairment and diagnoses including Tourette's Syndrome and dementia, was prescribed Risperdal 4mg twice daily without any attempt at GDR or documentation of contraindications from April 2024 to November 2024. The Director of Nursing (DON) admitted reliance on the pharmacist to manage GDRs according to CMS guidelines, but no such reductions were documented. Resident #13, diagnosed with paranoid personality disorder and dementia, was prescribed Risperdal 0.5 mg twice daily since March 2023. Despite a previous suggestion by the consultant pharmacist to reduce the dose due to potential side effects, the attending physician disagreed without providing a reason. The resident's care plan included consulting with the pharmacy and medical doctor for dosage reduction when clinically appropriate, but no further GDR attempts were made after the initial failed attempt. Resident #37, a male with vascular dementia and other mental health conditions, was prescribed Ativan and Risperidone without appropriate diagnoses for antipsychotic use. The Ativan was ordered as needed without a 14-day stop date, contrary to facility policy. The DON acknowledged the lack of appropriate diagnoses for antipsychotic use and the absence of a stop date for the PRN Ativan, which could lead to unnecessary medication use. The attending physician and consultant pharmacist confirmed the inappropriate use of antipsychotics for altered mental status, which is not an approved diagnosis for such medications.
Inadequate Hand Hygiene Practices in Infection Control
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of LVN T, who did not perform hand hygiene after taking a blood sugar reading from a resident. This incident involved a resident with a history of diabetes mellitus, congestive heart failure, and Alzheimer's disease. The resident was on a care plan that included monitoring and managing diabetes through medication and regular blood sugar checks. On the day of the incident, LVN T entered the resident's room, took her blood sugar, and administered insulin without washing or sanitizing her hands before the procedure. Interviews with various staff members, including LVN T, LVN U, ADON B, RN Q, LVN S, ADON C, the DON, and the ADM, revealed a consensus that proper hand hygiene should be performed before and after resident care, especially when dealing with bodily fluids like blood. LVN T acknowledged the importance of hand hygiene in preventing the spread of germs and infections, such as COVID-19, but admitted to feeling uncomfortable when questioned about her actions. Other staff members reiterated the necessity of hand hygiene to prevent cross-contamination and infection, emphasizing that improper practices could lead to negative outcomes for residents. The facility's hand hygiene policy, last revised in October 2022, mandates the use of alcohol-based hand rubs or soap and water before and after direct contact with residents and after contact with blood or bodily fluids. The facility's infection control policy, revised in December 2023, outlines the importance of minimizing infection spread through proper hand hygiene. Despite these policies, the failure to adhere to them in this instance placed residents at risk of exposure to communicable diseases and infections.
Failure to Monitor Antibiotic Use for a Resident
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program by not including Resident #37 in the Tracking and Trending Log for antibiotic use. Resident #37, who was treated for a urinary tract infection with Ciprofloxacin, was not monitored as required by the facility's policy. The resident, who had a BIMS score indicating no cognitive impairment, was admitted to the hospital with a urinary tract infection and discharged with a prescription for Ciprofloxacin. Despite the administration of the antibiotic as ordered, the resident's antibiotic use was not tracked, which is a critical component of the facility's antibiotic stewardship program. Interviews with the facility's staff, including the Infection Preventionist and the Director of Nursing, revealed that Resident #37 should have been included in the tracking and trending process. The Infection Preventionist acknowledged the oversight and its potential impact on the accuracy of monitoring antibiotic use and the effectiveness of staff in-services. The Director of Nursing and the Administrator both expressed that they expected the resident to be monitored for antibiotic stewardship, highlighting a lapse in following the facility's established procedures for monitoring antibiotic use.
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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) |
|---|---|---|---|---|
| Brentwood Terrace Healthcare And Rehabilitation | 1.8 mi | — | 3 | 0 |
| Avir At Paris | 2.2 mi | — | 5 | 0 |
| Stillhouse Rehabilitation And Healthcare Center | 2.3 mi | — | 0 | 0 |
| Heritage House At Paris Rehab & Nursing | 2.9 mi | — | 13 | 0 |
| Honey Grove Nursing Center | 20.9 mi | — | 9 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.