Health inspection·January 23, 2025

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Few Findings include: R1 was admitted to the facility on [DATE] with a diagnosis of respiratory failure, tracheostomy, dysphagia and substance abuse. R1's face sheet dated 1/14/25 documents under contacts: V4 (R1's family) as emergency contact one. V8 (state guardian) listed as third contact. R1's admission paperwork dated 11/19/24 documents: V8 as legal guardian with different phone number listed when compared to R1's face sheet. On 1/21/25 at 11:56AM, V3 (R1's state guardian) said they have not been notified of any concerns, consents, hospitalization for R1 since admission to the facility in November. On 1/23/25 at 12:35PM, V3 said although a person is assigned to a resident all agents can act on the behalf of the resident. V3 said if the facility was having difficulty in contacting the assigned agent, the facility should have contacted the main office to speak to management or another agent for any concerns. On 1/22/25 at 1:07pm, V6 (Social service) said upon admission they will verify resident information with hospital records, resident and/or family. V6 said she left messages for V8 (state guardian) with no return calls. V6 said social service is responsible for obtaining guardian paperwork at time of admission. V6 said they usually will get paperwork at initial care plan meeting within a week of admission. V6 said she does not recall reaching out to the main number at state guardian's office. V6 said R1's sister was being notified for all information pertaining to R1. On 1/22/25 at 1:48PM, V7 (social service director) said, Within 72 hours of admission, staff meet with resident and reach out to family or representative. If a resident has a guardian, we make sure the contact information is in the medical record, we will reach out to the guardian and schedule meeting with them within week of admission. Staff are supposed to reach out the obtain guardian paperwork upon admission. V7 said he was aware of staff not being able to contact V8 (former state guardian) but said he did not call anyone else to ask about R1's guardian. R1's consent for psychotropic medication dated 12/9/24 documents: V4(R1's family) gave phone Page 1 of 2 145334 145334 01/23/2025 Rivaya Care of Des Plaines 9300 Ballard Road Des Plaines, IL 60016

F 0745 consent. Level of Harm - Minimal harm or potential for actual harm R1's progress note dated 12/9/24 documents: consent given by V4(R1's family) through phone call for Lorazepam Tablet 0.5 MG every 8 hours as needed. General update given to the V4. Residents Affected - Few R1's progress note dated 1/6/25 documents: This writer spoke with V4 (R1's family) in regard to transfer to another facility. V4 (R1's family) verbalized understanding of transfer/discharge process. Would appreciate any communication. R1's progress note dated 1/4/25 documents: V4 (R1's family) notified with room change and sputum culture partial result. R1's progress note dated 12/22/24 documents: resident received back from the local hospital. R1 was seen and examined at bedside by Nurse Practitioner with new order hydroxyzine 25 mg every 6 hours. V4 (R1's family) called and updated will all new orders and consented hydroxyzine to be given. Facility social service responsibilities undated documents: maintain standard of documentation in the resident's records, including initial assessment note and as needed; Coordinate with outside agencies such as case managers, insurance agencies and the ombudsman and state and public guardian for the continuity of care. Facility policy on Adult Guardianship in Illinois undated documents: The facility will reach out upon admission to guardian, including the identified representative. The guardian contact information shall be identified in the clinical record along with documents proving guardianship. Facility policy titled Resident change in condition reviewed 2/2/24 documents: Regardless of the residents current mental, medical or physical condition a nurse or provider will inform the resident and residents representative/guardian of any changes in his/her condition, any incident or accident, including changes in medical care or nursing treatments. 145334 Page 2 of 2