F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
R1 is a [AGE] year-old female admitted to the facility with diagnosis including but not limited to End Stage
Renal Disease; Cerebral Infarction Due to Unspecified Occlusion Or Stenosis Of Left Posterior Cerebral
Artery; Depression; Borderline Personality Disorder; Suicidal Ideations; Bipolar Disorder; Torsade De
Pointes; Pulmonary Hypertension; Cocaine Abuse; and Major Depressive Disorder.
On 06/03/2025 at 12:12 PM R1 said, I was sitting in the hallway, in my wheelchair and I had a stuffed
animal (the lion) in my lap. R2 came up to me, complemented my stuffed animal, and asked if he could
touch it. I lifted the stuffed animal for R2 to see, but R2 reached out towards my private part and touched
my private part instead. I reported it and talked about it every day. I notified the police to file for restraining
order. The police came out about 3 weeks ago. They gave me report number, but I don't know what
happened to it. I gave it to V6 (Activity Assistant). V5 (Social Service Director) confronted me in front of
police officers, and asked me what time and day it happened, knowing I wouldn't know what time and day it
happened. The police told me they dropped the case because no one has seen what happened. Nobody
actually seen it, because nobody was around.
On 06/03/2025 at 1:34 PM V6 (Activity Aid) said, R1 participates in activities but it's based on her mood. I'm
familiar with R1 though. R1 never mentioned anything about R2 groping her. R1 never gave me any police
report number. I don't know of R1 calling police recently.
On 06/03/2025 at 2:00 PM V1 (Administrator/Abuse Prevention Coordinator) said, I never heard of the
incident alleged by R1. I see R1 almost daily, she comes to my office at least weekly, but she never
mentioned anything to me. Never mentioned any resident was inappropriate towards R1. If there is an
abuse allegation, resident safety is our priority, then reporting and investigation. If the perpetrator is an
employee, the employee would have to be suspended, and we would then complete interviews with staff
and residents.
On 06/03/2025 at 3:08 PM V8 (Licensed Clinical Social Worker) said, I met with R1 on 05/30/2025 to
terminate services due to new corporation terminating my contract. I was seeing her for about a year and
half. R1 told me, during most recent session (05/30/2025), something that occurred with another resident,
allegedly, he touched her inappropriately. R1 told me police was here to investigate it.
(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
06/04/2025
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)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
R1 said V1 (Administrator/Abuse Prevention Coordinator), and other staff knows about it. I trusted that
everyone already knew. In hindsight, I realized that I should have checked if R1, in fact, reported it to other
staff. I felt that if R1 said that the police were here to investigate, I couldn't have report it to anyone else. I
believed and trusted R1.
On 06/03/2025 at 3:15 PM V1 (Administrator/Abuse Prevention Coordinator) said, V8 (LCSW) should have
reported the incident to me, but she didn't. I just found out about the incident today, from you. I will report it
to the regulatory agency and initiate the alleged abuse investigation.
Progress note dated 05/30/2025 10:11 AM written by V8 (LCSW) reads in part, Met with (R1) in hallway.
(R1) expressed her frustration with confines of SNF environment. (R1) mentioned she was interviewed by
detectives regarding an incident that happened with another resident. (V8) provided validation of feelings
and a safe space to express her emotions.
The facility Abuse Prevention (no date) reads in part, Employees are required to report any incident,
allegation or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of
resident property they observe, hear about, or suspect to the administrator immediately, to an immediate
supervisor who must then immediately report it to the administrator or to a compliance hotline or
compliance officer. In the absence of the administrator, reporting can be made to an individual who has
been designated to act in the administrator's absence.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145334
If continuation sheet
Page 2 of 2
