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 (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 01/23/2025 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)