Health 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physician to revoke the guardianship and the facility did not provide any court documentation that R1's guardianship was revoked.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. Page 1 of 2 145334 145334 06/22/2025 Rivaya Care of Des Plaines 9300 Ballard Road Des Plaines, IL 60016

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 6/20/2025 at 4:30 PM V2 (Director of Nursing) said, I expect staff to call resident's representative/guardian to inform of discharge planning, orders, and discharge location. I do not see any records of V4 notifying the guarding under the resident's electronic notes. On 6/20/2025 at 4:30 PM V2 (Director of Nursing) provided a policy titled, Transfer and Discharge Guideline reviewed dated 10/2024. Which reads in part (but not limited to), Policy: Orientation for transfer/discharge a. The facility will provide the resident with sufficient orientation to the upcoming discharge to ensure the discharge is safe and orderly. The orientation will provide the resident or representative in a form and manner that can be understood. Notifications: Notify family/responsible party, physician, and applicable agencies (e.g., ombudsman case manager) as needed. 145334 Page 2 of 2