Rivaya Care of Des Plaines

Inspectors wroteBased on interview, record review, and policy review, the facility failed to follow its written abuse prevention policy when administration did not enforce policy rules after confirming a Certified Nursing Assistant (V3) crossed professional boundaries with a resident (R1) and deleted social media evidence during an internal investigation. This failure by management to enforce its abuse policy puts all 133 residents in the facility at risk for unchecked staff misconduct.

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate personal property inventory and failed to safeguard personal belongings for 1 of 3 resident (R2) reviewed for missing personal property. Specifically, the facility failed to complete or provide an itemized personal inventory list upon admission or during care, and failed to investigate or provide objective evidence to substantiate the whereabouts of R2's missing wedding ring and fur coat.

Inspectors wroteBased on interview and record review the facility failed to ensure 1 of 3 residents (R1) reviewed for abuse was protected from staff boundary violations and potential emotional exploitation when Certified Nursing Assistant (V3) established an unauthorized personal social media relationship with R1, causing R1 emotional distress, and deleted her account history during the facility's investigation. Findings Include:R1 is a [AGE] year-old alert and oriented resident with diagnoses including diabetes, heart failure, protein-calorie malnutrition, and radiculopathy of the lumbar region. A review of R1's Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15, confirming intact cognition (alert and oriented x 3), with no documented diagnoses of mental illness or behavioral symptoms. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement fall preventive measures for R1 who require floor mats next to bedside for safety precautions. This deficiency affects one (R1) of three residents reviewed for Falls prevention program.

Inspectors wroteBased on interview and record review, the facility failed to follow their Staffing Policy by not having the appropriate staff available to meet the needs of the residents resulting in a resident (R1) fall. This failure affected one (R1) of three residents reviewed staffing.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure facility's daily nurse staffing information form posted at the front desk. This failure has the potential to affect 102 residents receiving care in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medications were administered as ordered by the physician for one of three residents (R3) reviewed for medication administration.

Inspectors wroteBased on observation, interviews and record review the facility failed to implement medication self-administration policy affecting 1 of 3 (R1) residents reviewed for medication administration. Findings Include:On 3/5/2026 at 11:00AM during observation, two insulin pens (Lantus and Lispro) and Acetaminophen 325mg bottle were on top of R1's bedside table. Insulin pens and Acetaminophen bottle were not labeled. R1 said staff are aware of the medications at bedside. During the interview R1 said she's not able to self-administer insulin since she returned from hospitalization on 2/25/2026 because her hands are weak, but she was self-administering insulin and checking blood sugar before. R1 stated she's self-administering Acetaminophen/Tylenol now and facility is aware of it. On 3/5/2026 at 11:20 AM, V5 (Registered Nurse) said medications should not be left at bedside. [...]

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure medications were safely stored, affecting 1 of 3 (R1) residents reviewed for medication storage. Findings Include:On 3/5/2026 at 11:00AM during observation, two insulin pens (Lantus and Lispro) and Acetaminophen 325mg were on top of the bedside table. Insulin pens and Acetaminophen bottle were not labeled. Insulin pens and bottles did not have an identification such as resident name, date opened and discard date. R1 said staff are aware of the medications at bedside. On 3/5/2026 at 11:20 AM, V5 (Registered Nurse) said medications should not be left at bedside. Medications should be labeled with name, date open and discard date. On 3/5/2026 at 11:23 AM, V3 (Assistant Director of Nursing) said medications should not be stored at bedside. Medications should include clear labeling. [...]

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure staff donned required personal protective equipment (PPE) prior to entering rooms of residents on Enhanced Barrier Precaution (EBP) transmission-based protocol for four (R52, R100, R47, R54) of four residents reviewed for infection control is a sample of 42. This failure had the potential to expose residents and staff to the transmission of infectious agents. R52 is a [AGE] year-old male who originally admitted to the facility on [DATE] and continues to reside in the facility. R52 has multiple diagnoses including but not limited to the following: encounter for attention to gastrostomy, tracheostomy status, dependence on respirator [ventilator] status. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow maintenance work orders policy by not providing a home-like environment by not implementing an effective remedy, within the expected timeframe, to fix a broken toilet. This failure affected 1 (R1) of 3 residents reviewed for Furnishings / Equipment Not maintained. On 11/25/2025 at 10:19 AM R1 stated he notified housekeeping department, maintenance, social worker, and the administrator on October 6, 2025 that R1's toilet broke and if flushed leaks in his room. R1 stated he reported the malfunctioned toilet to the housekeeping department, maintenance director, social worker, and the administrator. R1 stated it has still not been resolved. On 11/25/2025 state agency observed a broken toilet (at the base of a manual flush valve), with no handrails attached. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to follow fall policy related to prevention of falls and implementation of resident-centered fall interventions on a resident with cognitive impairment. This failure affected one (R1) of five residents reviewed for accidents and supervision and resulted in R1 falling while walking without staff assistance and sustaining a right intertrochanteric hip fracture with associated intramuscular hemorrhage.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to notify resident's representative of discharge planning, orders, and arrangements for post-discharge care for one resident (R1) out of three residents reviewed for representative notifications.

Inspectors wroteBased on interviews and record review, the facility failed to identify and report an allegation of sexual abuse to the facility's abuse prevention coordinator and further to regulatory state agency for one of four (R1) residents reviewed for abuse in the sample of four.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure ongoing assessment, monitoring is implemented to identify new skin impairment to resident who is at risk and to notify physician for appropriate wound treatment. The facility failed to follow wound care treatment as ordered by physician. The facility failed to update wound care plan for newly identified wound and notify the family member. The facility failed to follow manufacturer recommendation in using low air loss mattress. This deficiency affects all four (R2, R3, R4, R5) residents reviewed for Pressure ulcer/Wound Prevention and Treatment Management.

Inspectors wroteBased on interview and record review, the facility failed to verify and obtain one resident's (R1) state guardian information. This failure resulted in the facility failing to notify the correct guardian and obtaining consent from resident's family for one of three residents reviewed for social services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an enteral feeding was administered as ordered for three (R5, R10, R12) of six residents reviewed for enteral feeding in the sample of 14. This failure resulted in R10 sustaining insidious weight loss of seven pounds in one month.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician order in providing wound treatment. The facility failed to implement wound prevention management. The facility also failed to follow manufacturer recommendation in using low air loss mattress for resident with multiple stage 4 pressure ulcers. This deficiency affects all five (R1, R4, R5, R6 and R7) residents reviewed for Wound care management.

Inspectors wroteBased on interview and record review the facility failed to protect the resident from unwelcome physical touch of another resident to her shoulder. This deficiency affects one (R3) of three residents reviewed for Abuse prevention Program.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement fall precaution interventions for two (R3, R4) residents identified as a fall risk in a sample of three residents reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor and prevent a high risk cognitively impaired resident from sustaining a preventable fall, failed to provide fall preventative devices, failed to develop/implement a plan of care for residents at high risk for falls, and failed to educate staff on identifying and protecting residents from accidental falls. This failure affects 1 (R57) of 1 residents reviewed for falls in the sample of 28. R57 was admitted to the hospital with a left comminuted (multiple bone breaks) femur fracture with surgical intervention as a result of this failure.

Inspectors wroteBased on observation, interview and record review the facility failed to recognize, evaluate and manage pain for a 1 (R57) resident with severe cognitive impairment of 3 residents reviewed for pain management in the sample of 28 residents. This failure affected R57 receiving inadequate pain medication after an unwitnessed fall, and failure to thoroughly assess and monitor for further pain for over 48 hours until being emergently sent to the hospital for treatment of a femur fracture requiring surgical intervention.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow manufacturer's instructions for the proper operation and functioning of the facility's pressure relieving air mattresses for 4 residents (R54, R18, R41, R121) in the sample of 28 reviewed for pressure ulcer prevention and management.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy on incident reporting within twenty-four hours of an unwitnessed fall with serious harm or injury to a resident to IDPH Illinois Department of Public Health and provide a final summary completed within 7 days. This failure applies to one (R57) of 1 resident reviewed for reporting of falls. R57 was admitted to the hospital with a left comminuted (multiple bone breaks) femur fracture with surgical intervention.

Inspectors wroteBased on interview and record review, the facility failed to notify physician of abnormal results for urinalysis in a timely manner for 1 (R125) of 3 resident reviewed for laboratory services in the sample of 43.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to medically manage a brittle Type 1 diabetic by failing to follow physician orders in administering insulin orders and obtaining blood glucose levels; failed to administer anti-seizure medications for a resident with a history of seizure disorders; and failed to have a care plan in place for a resident with history of seizure disorders. This failure applies to 1 resident R1 of 3 residents reviewed for quality of care and resulted in the emergent transfer to the ER (emergency room) to receive immediate critical care for treatment and prevention of imminent life-threatening deterioration of dehydration, endocrine crisis, and metabolic crisis.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their abuse policy by not protecting a resident from abuse and/or preventing a physical assault in 2 separate incidents on the same day for 2 (R5, R6) of 4 residents reviewed for abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate nutrition by not following dietary order for 2 of 3 residents (R7, R13) reviewed for nutrition in the sample of 13. This failure has a potential to affect all 28 residents on NAS (No Salt Packet on Tray) diet.

Inspectors wroteBased on interviews and record review, the facility failed to protect the resident's right to be free from sexual abuse by staff. This failure applied to one of one (R1) resident reviewed for sexual abuse and resulted in R1 being sexually abused by a facility CNA (Certified Nurse Aide). The Immediate Jeopardy began on 2/4/24 when R1 was sexually abused by a male facility CNA. V1 (Administrator) and V4 (Regional Director of Operations) were notified of the Immediate Jeopardy on 2/20/24 at 2:20PM. The surveyor confirmed by interview and record review, that the Immediate Jeopardy was removed on 2/21/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.

Inspectors wroteBased on interviews and record review, the facility failed to have a system in place to prevent residents from potential abuse by staff after an allegation of staff to resident sexual abuse was made and while allegation was still pending investigation by law enforcement. This failure applied to one of one (R1) resident reviewed for sexual abuse investigation and has the potential to affect the 146 residents currently in the facility. The Immediate Jeopardy began on 2/14/24 when V5 (CNA) was allowed to return to work with no mitigating interventions put in place to protect residents from further abuse after V5 was identified as being a potential aggressor in an allegation of sexual abuse that is still under investigation with local law enforcement authorities. V1 (Administrator) and V4 (Regional Director of Operations) were notified of the Immediate Jeopardy on 2/20/24 at 2:20PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to ensure one resident received two showers per week. This affected one of three (R15) residents reviewed for showers.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to implement intervention in preventing the development and worsening of pressure ulcers on a resident with physical and cognitive impairment. This failure applied to one (R36) of three residents reviewed for skin breakdown and resulted in R36's intact skin developing an unstageable pressure ulcer on the right buttock and right ischium; and Stage 3 pressure ulcer on the left ischium worsened into Unstageable.

Inspectors wroteBased on observation interview and record review, the facility failed to provide an individualized program for supervision to prevent recurring falls for a resident and prevent a resident who is NPO from eating and drinking by mouth (R12), failed to ensure a proper system was in place for safe and secure transfers and failed to safely transport one resident (R124) while riding on the facility bus. This failure affected two residents (R12 and R124) of seven residents reviewed for accidents. R12 have had four falls since admission, was sent to the hospital after the last fall and returned to the facility with four staples to the right top forehead. R12 has been drinking his G-tube feeding, stealing, and eating food and is currently receiving antibiotic treatment for possible aspiration on food. R124 sustained two fractures to two of the right ribs during transfer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy on the use of hair restraints, failed to obtain the appropriate sanitation level in the three compartment sink for dish washing, failed to label and date opened food in the freezer, failed to sanitize the thermometer when obtaining food temperatures, failed to perform hand washing, failed to keep food dispensing cups covered, failed to follow standardized recipes and food preparation directions. This failure has the potential to affect all 121 residents who receive meals from the kitchen.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their policy and procedures for treatment and services of mental/psychosocial concerns by not performing social service history/behavior assessments quarterly and by not providing sufficient psychosocial/behavioral services for residents with multiple mental health diagnoses that require psychosocial/behavioral health services. This failure applies to four of four residents (R12, R29, R50, and R121) reviewed for mood and behavior.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their policy and procedures for treatment and services of mental/psychosocial concerns by not ensuring there is enough staff to meet the needs of residents who require these services. This failure applies to four of four residents (R12, R29, R50, and R121) reviewed for mood and behavior.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their Resident's Rights policy by not ensuring one resident (R107) was treated with dignity and respect. This failure applied to one (R107) of one resident reviewed for resident rights.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and ensure one resident (R113) received their requested medical records in a timely manner. This failure applied to one (R113) of one resident reviewed for medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1. follow their medication administration policy by not remaining with the resident to ensure that the resident swallows administered medication and 2. failed to keep the bedside free of medications not in use. These failures applied to two (R60, R73) of two residents who were reviewed for medications administration.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure one resident's airway (R18) was free of any obstruction and failed to perform effective bag-valve to tracheostomy resuscitation during a code blue. This failure resulted in R18's airway being obstructed with suction catheter tubing in her tracheostomy preventing adequate oxygenation for at least 7 minutes until Emergency services arrived when it was removed. This affected one of three residents reviewed for death. The Immediate Jeopardy began on [DATE] when R18 was not provided effective bag-valve-mask tracheostomy resuscitation. V1 (administrator) and V2 (director of nursing) were notified of the Immediate Jeopardy on [DATE] at 10:53AM. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to notify the physician of an acute change in condition on [DATE] and failed to immediately activate 911 for an acute change in condition. R7 was exhibiting lethargy, blue discoloration to fingertips, slow speech, glazed eyes, and a critically low sodium level. This affected one of three resident (R7) reviewed for change of condition, and emergency management response. This failure resulted in R7 being left unmonitored with a declining clinical status for over 14 minutes. R7 was found unresponsive without pulse/respiration by the local EMS team who initiated lifesaving interventions to include CPR. However, R7 expired. The immediate jeopardy began on [DATE] when R7 experienced an acute change in condition and the facility failed to monitor and failed to immediately activate 911. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to monitor/supervise a resident requiring assistance in the shower room and failed to ensure effective fall prevention interventions were in place to prevent fall incidents. This affected 2 of 4 residents (R19, R2) reviewed for falls and fall prevention. This failure resulted in R19 being in the shower room, unmonitored, experiencing an unwitnessed fall sustaining a cervical spine fracture requiring immediate surgery. This failure also resulted in R2 having four falls in three weeks.

Inspectors wroteBased on interviews and record reviews, the facility failed to notify the physician of chest x-ray results for one resident (R7) out of three reviewed for diagnostic imaging.

Inspectors wroteBased on interview and record review, the facility failed to have a policy that allowed twenty-four-hour access. This affected two of three residents (R1 and R4) reviewed visitation and facility access. Findings Include: On 9/13/23 at 4:24PM, V12 (R1's POA) said, I am not allowed to visit R1 after 8pm nor is any of R1's family. On 9/20/23 at 10:01AM, V9 (social service coordinator) said, visiting hours are from 10am -8pm daily. If a visitor doesn't want to leave when visitation hours were over, V11 (receptionist) would go and talk to them. R1 had a lot of visitors who did not want to leave when visitation hours were over. On 9/20/23 at 10:31AM, V11 said, she would make an announcement over the public announcement system at 7:30pm to tell visitors that visitation hours would be ending at 8:00pm. V11 said, she would make rounds, walking the units to check resident's rooms for visitors. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its physician notification policy and notify the physician immediately of acute changes in a resident's condition. This failure affected one resident (R7) out of three reviewed for physician notification.

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy by not ensuring one of three residents reviewed for misappropriation of funds. This failure resulted in R3 having two unauthorized purchased from her bank debit card by V7 (transportation clerk) totaling $257.29. Findings Include: R3 was diagnosis with cerebral infarction. R3's minimal data set section C (cognitive pattern) brief interview for mental status dated 8/22/23 documents a score of fifteen which indicated cognitively intact. On 9/13/23 at 1:04pm, R3 who was assessed to be alert and oriented to person place and time, said, I gave V7 (previous transportation clerk) my bank card to go to the store to purchase some personal items for me. V7 made my requested purchase for $77.91 at a retail big box store. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to report an injury of an unknown origin after being informed of R1 having multiple unexplained bruising to the body. This failure affected one resident (R1) out of three reviewed for abuse reporting.

Inspectors wroteBased on interviews and record reviews, the facility failed to initiate an abuse investigation after being informed of R1 having an unknown bruise. This failure affected two residents (R1) out of three residents reviewed for abuse investigations.

Inspectors wroteBased on interview and record review, the facility failed to ensure two staff members V54 (respiratory therapist) and V63 (nurse) had valid cardiopulmonary resuscitation (CPR) cards while providing basic life support to one resident (R18) during a code blue for two of five staff members reviewed for valid CPR card.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (R18) was competent to safely self-suction via tracheostomy and failed to implement a plan of care for self-suction for one of three residents reviewed for respiratory care.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain complete and accurate resident medical records for two resident (R7, R2) out of three reviewed for accuracy of documentation.