Inspection·September 29, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few where R1 was. That time it was only me and the nurse worked on the west wing. Normally, he (R1) ambulates with a walker. there's no assistance needed because he can do it by himself. He can walk around by himself. He doesn't need assistance to walk around. He has no chair or bed alarm, not that I know of.On 09/24/25 at 2:53 PM, V11 (Licensed Practical Nurse, LPN) said, That time of incident on 09/19/25, I was on 1 East, because one nurse left at 1 AM and I was the only nurse on the first floor. I had two CNAs - one in west and one in east. CNA was sitting at the nurses' station. I heard CNA called me, I went there, and I saw R1 on the floor. I did assessment. I asked him (R1) and said he was walking. I asked him about pain and showed me his right hip. I gave him PRN (when needed) pain pill. I called physician he was sent out as ordered. V11 said, He is alert, oriented to self, time and place, able to verbalize needs. he never uses call light; always sitting in his room. His room is somehow close to nurse station. At night, sometimes, he was awake and will call nurse, nurse. He usually sits in bed and will call nurse, nurse. When we go to his room, he doesn't say anything. If you tell him to sleep, he will lie in bed. I don't know if he is a fall risk, it was the second time I took care of him. I've never seen him walking with a walker, only time he had was when he had the fall.R1's room was observed across nurses' station (1West). R1's door is on the side across nurses' station.On 09/25/25 at 10:25, V12 (Registered Nurse, RN) stated, R1 is very much confused; he talks nonsense. Not able to use call light. He is very much a fall risk patient. His room was just across the station. We always monitor and check on him at least every two hours. CNAs do their rounds also. RNs and CNAs do monitor at least every two hours. I always tell my CNAs to monitor him. I do my rounds then CNAs, so more or less he is monitored and checked every hour. He gets up, he has a rollator. He is able to use rollator with supervision from staff. He uses his rollator with reminders but if not, he won't use it. His legs are weak and has unsteady gait. He needs monitoring/supervision frequently and make sure he uses the rollator when he walks.On 09/25/25 at 10:52AM, V14 (CNA)verbalized, R1 is alert but confused. Able to verbalize needs. He is not able to use call light, he uses a rollator. He is supposed to use a wheelchair. We always redirect him. He always wanted to use the rollator. He is a fall risk. We have to monitor and check on him pretty often, at least every 2 hours and when we do rounds, we check on him. He has no alarms. bed should be lowered. He has a behavior of getting up and walk, needs redirection. He needs to be reminded to use the wheelchair not rollator.On 09/25/25 at 11:14 AM, V5 (LPN/Restorative Coordinator replied, On 09/19/25 at 1:30 AM, he got up from bed, attempted to self-transfer. Did not tell nurse where he was going. The CNA heard him fall, the CNA said she was doing patient care in another patient's room. When the CNA heard it, she went to the room and found him lying on his right side, the walker was next to him. The nurse came and assessed him, he was in pain to his right hip. The nurse called the doctor and R1 was sent out to the hospital. Cause of the fall - R1 was getting up and due to unsteady gait, he fell. Staff should have done rounding/monitoring at the time to ask if he needs something. Rounding/monitoring should be every hour like nurse simultaneous with CNA doing rounds; he might need to go to the bathroom at the time because it was around 1:30 AM but no one was around, cognitively he forgot to use the call light, and he did not know his limits and walked. He gets up when he wants to and walk. He uses a walker with staff assistance. R1 definitely has confusion. Somebody has to monitor and do an hour rounding on him. R1's care plans documented the following:1. Requires restorative walking program due to his limitation in walking related to weakness (dated 09/12/25):Interventions:Discuss ambulation program with resident and responsible party.Provide staff assist with ambulation at level resident requires (e.g. set up, oversight, encouragement, cueing, physical assistance).Remind resident to not ambulate without assistance.2. Resident is high risk for falls (dated 09/11/25):Interventions:Anticipate and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145334 If continuation sheet Page 2 of 3 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 09/29/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete meet the res needs.Be sure the resident (R1) call light is within reach and encourage the resident (R1) to use it for assistance as needed. The resident (R1) needs prompt response to all requests for assistance.Educate the resident (R1)/family/caregivers about safety reminders and what to do if a fall occurs.Follow facility fall protocol.The resident (R1) uses (specify: chair/bed) electronic alarm. Ensure the device is in place as needed. R1's care plan interventions focused on his (R1) education, reminders and use of call light when assistance is needed. However, R1 is confused and forgetful. R1's Progress notes dated 09/11/25 documented in part but not limited to the following: R1 was observed up in chair, in no acute distress, eating breakfast, denies pain currently, alert and oriented to self, with noted confusion, requiring redirection per staff. On 09/25/25 at 1:19 PM, V2 (Director of Nursing) stated, He is a fall risk. He came from the hospital because of a fall. He is alert, in and out, able to hold a conversation with you. He can tell you his needs and wants but detailed conversation and remembering things, not really. He needs to be redirected. He had a fall early in the morning, like at 1:30 AM, he got up and walked. His legs gave out when he was walking using the walker. It was unwitnessed fall, so he could not be redirected.Per admit evaluation note dated 09/11/25, R1 uses a wheelchair due to gait disturbance and unsteady gait. Per care plan, R1 uses electronic alarm, but was not implemented.On 09/25/25 at 10:46 AM, V13 (Nurse Practitioner) stated, R1 is confused with place and time, he has dementia, able to verbalize needs. He sits in the wheelchair. I have not seen him walk. He is a fall risk. Rounds/monitoring should be done; making sure bed is locked; wheelchair locked; wearing non-skid socks; and follow the facility fall protocol. Facility's policy titled, Falls Guideline, dated 8/2024 documented in part but not limited to the following:Purpose: To consistently identify and evaluate residents at risk for falls and those who have fallen to treat or refer for treatment appropriately and develop an organization-wide ownership for fall prevention to:To achieve each resident's maximum potential of physical functioning.To prevent or reduce injuries related to falls.To enhance residents' dignity and self-worth.The intent of this guideline is to ensure this facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident as identified through the following process:I. Identification of hazards and risksII. EvaluationIII. ImplementationIV. MonitoringV. AnalysisFall risk evaluation: a fall evaluation is used to identify individuals who have predicting factors for falls. This evaluation is completed upon admission, quarterly, annually and with a significant change in condition. Residents evaluated as at risk for falls will be identified and individualized fall precautions developed for each resident. Preventative measures shall be taken to decrease the number of falls whenever possible.Purpose:1. To consistently identify and evaluate residents who fall and to treat or refer for treatment appropriately.3. To prevent or reduce injuries related to falls.6. Individualize interventions for each resident.Evaluation may include: Residents with recent surgery or new admission; fall history; cognitive status1. If the evaluation finds the resident at risk, implement resident specific interventions/precautions.7. All residents identified as at risk for falls will be reviewed for individualized interventions.Fall Prevention is achieved through an IDT (interdisciplinary team) approach of managing predicting factors and implementing appropriate interventions to reduce risk for falls. Facility staff across all departments together with resident representatives and residents provide resourceful information with individualizing care and approaches.Understanding contributing and predicting factors that present will assist with determining individualized care approaches.Systems approach - Tips for Compliance:Involve interdisciplinary team (IDT) on: Individualized assessment for safety; identification of hazards; Development and implementation of interventions to reduce accidents. Event ID: Facility ID: 145334 If continuation sheet Page 3 of 3