Inspection·December 13, 2024

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 12/13/24 at 10:07 AM, R5 was observed lying in bed, his enteral feeding Osmolite 1.5 was infusing at 75ml (milliliter) /hr. (hour). At 12:11 PM, R5 was lying in bed, his enteral feeding remained infusing at 75 ml/hr. R5 was eating his noon meal. He was served two hot dogs and mashed potatoes for the noon meal. He had consumed about 90 % of his meal. R5 said he is not sure when his tube feeding gets disconnected, he is getting the tube feeding because he had poor intake. On 12/13/24 at 12:18 PM, V13 (RN) said enteral feedings orders should be followed according to the prescribed order. She said R5's intake was poor and was receiving the enteral feeding to supplement his intake. V13 said R5's enteral feeding should be off at 5:00 AM and on at 9:00 PM. Night shift staff should have stopped his feeding. She said she saw R5's feeding was infusing and did not know it was supposed to be off. Infusing to much could put the resident at risk for fluid overload. R5's Physician Order Sheets (P.O.S.) dated through December 2024 shows he is [AGE] year-old male with diagnoses including COPD, heart disease, congestive heart failure, asthma, Crohn's, and hypertension. The P.O.S. shows orders for enteral feed order Osmolite 1.5 at 75 ml/hr. x 8 hours. Off at 5:00 AM and ON at 9:00 PM. The facility's Tube Feeding Policy reviewed date 2024 states, Nasogastric, gastrostomy and jejunostomy tube are used when an alternate method of nutrition is needed .all tube feeding orders will include the formula, rate, time period, delivery method and flush . feeding pump: turn on pump, set prescribed rate and start feeding . Based 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. Findings include: 1. On 12/13/24 at 10:28 AM, R10 was in bed sleeping with an enteral feeding connected and running at 60 ml/hr. On 12/13/24 at 11:50 AM, R10 was in bed with an enteral feeding connected and running at 60 ml/hr. On 12/13/24 at 12:50 PM, V5 Registered Nurse reviewed R10's orders and said R10's enteral feeding should be Glucerna 1.5 running at 65 ml/hr. V5, with this surveyor, observed R10's enteral feeding (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145334 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145334 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rivaya Care of Des Plaines 9300 Ballard Road Des Plaines, IL 60016 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)