Inspection·November 25, 2025

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, interviews, and record review, the facility failed to follow maintenance work orders policy by not providing a home-like environment by not implementing an effective remedy, within the expected timeframe, to fix a broken toilet. This failure affected 1 (R1) of 3 residents reviewed for Furnishings / Equipment Not maintained.On 11/25/2025 at 10:19 AM R1 stated he notified housekeeping department, maintenance, social worker, and the administrator on October 6, 2025 that R1's toilet broke and if flushed leaks in his room. R1 stated he reported the malfunctioned toilet to the housekeeping department, maintenance director, social worker, and the administrator. R1 stated it has still not been resolved.On 11/25/2025 state agency observed a broken toilet (at the base of a manual flush valve), with no handrails attached. The toilet bowl had more than half full of yellow urine and was filthy. A transparent garbage bag halfway covering the toilet bowel. R1 stated he tried covering the toilet bowl because of the odor.On 11/25/2025 V1 (Assistant administrator), V2 (Director of Nursing/ DON), V3 (Housekeeping Director), V4 (Licensed practical Nurse/ LPN), V5 (Maintenance Director), V6 (Social Service Director), were interviewed and stated they are aware of the allegation regarding a broken toilet. V6 stated he was made aware regarding R1's broken toilet on Saturday November 22, 2025. V6 stated he placed a work order and notified maintenance regarding the broken toilet. V6 stated that he was the one who spoke to R1 regarding the room change because the R1's toilet was broken and not functioning. V6 stated R1 refused to do a room change and was educated, however R1 refused. V4 stated she has known about the broken toilet for about 2 weeks and R1 uses the bathroom across his bedroom down the hall. V1 and V5 stated there was a miscommunication regarding ordering a toilet for R1's room. V5 understood that plant operator that works for the company had ordered the toilet R1's room. V5 and V6 stated the toilet was not ordered. Both V1 and V6 stated the toilet should have been fixed immediately. V6 stated the toilet will be fixed today, 11/25/2025.Facility Policy and Procedure: Maintenance Work Orders Revised.Purpose- The purpose of this policy is to establish a clear and consistent process for reporting documenting prioritizing and resolving maintenance related issues within the facility to ensure a safe functional and compliant environment for residents' staff and visitorsScope- this policy applies to all maintenance staff facility managers department heads and any employee who identifies or reports a maintenance concern.Policy- all maintenance issues must be reported promptly document wanted accurately and addressed in a timely manner according to the priority level regulatory requirements and resident safety considerationsProcedure- Reporting a problem. Any staff member who identifies a maintenance issue must report it immediately using the facilities approved TELS Work Order System. Maintenance staff responsibility: 1. the maintenance director (or designee) must check new work orders at the start of each shift and throughout the day and be able to identify and prioritize urgent issues. 3. Any issues that cannot be resolved with the expected time frame must be escalated to the administrator. If repairs may affect resident or their routines nursing leadership must be informed offer a room change if needed (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 11/25/2025 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)