Inspection·June 22, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: R1 is a [AGE] year-old resident admitted to the facility on [DATE] to 5/22/2025 with diagnoses including but not limited to: anemia, chronic obstructive respiratory disease, heart failure, cocaine abuse, and anxiety disorder. On the (MDS) Minimal data Set assessment of 5/17/2025 Section C the BIMS (Brief Interviewed Mental Status) score was 14/15 and indicates cognitive intact. On MDS of 4/4/2025 GG Section Functional Abilities indicates R1 can wheel 150 feet: Once seated in a wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space independently. R1 can walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space with setup or clean-up assistance - helper sets up or cleans up; resident completes the activity. Helper assists only prior to or following the activity. On 6/20/2025 at 11:52 PM, V3 (State Guardian) said, I sent one associate to see R1 on 6/9/2025 to the facility and R1 was discharged two weeks ago. I did not receive any update on discharge or any information about where the resident would be discharged . I spoke with V1 (Administrator) and V4 (Social Service Director) from the facility and confirmed that R1 was discharged . The facility sent me a form filled out by the physician to revoke the guardianship and the facility did not provide any court documentation that R1's guardianship was revoked. I went to the facility in January of 2025 for the first quarter assessments and visit. R1 has been under guardianship since May 9, 2022. On 6/20/2025 at 2:16 PM V4 (Social Service Director) said, I assisted R1 with discharge planning. I did not notify V3 (State Guardian) of the discharge planning for R1 before discharge. I messed up and I have to be honest with you. I should have notified the guardian, but I did not. Discharge planning is the primary responsibility of the social services, when there is no social service in the building, nursing is responsible and will call Power of Attorney/guardian or whoever the resident will appoint to assist with discharge. On 06/20/2025 at 12:27 PM V5(Vice President of Operations) said the facility does not have court documentation of the revoked guardianship for R1. I expect the staff to notify the resident's representative of discharge planning, orders, and location before the discharge. (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 06/22/2025 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)