Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rivaya Care Of Des Plaines during CMS and state inspections, most recent first.
A resident with multiple comorbidities (including COPD, CHF, epilepsy, Crohn’s disease, neuropathy, and use of psychotropics) was assessed as high risk for falls, and the care plan required floor landing mats when the resident was in bed. The resident later sustained an unwitnessed fall from bed with a head laceration while alert and oriented, and reported that no floor mats were in place at the time. Several CNAs and an agency nurse stated they did not see floor mats in place, while one CNA believed mats were present, and both the Administrator and DON confirmed that mats were not in use during the fall, despite facility policy requiring implementation of individualized fall-prevention interventions.
The facility did not follow its staffing policy when only two CNAs were present on a unit that was normally staffed with three, and the nurse assigned to a resident who fell was not on the floor at the time of the incident. The DON confirmed the unit was short-staffed due to a last-minute call-off, and an agency nurse on the opposite side of the unit reported that the assigned nurse was absent when the fall occurred, requiring the agency nurse to call 911 and provide first aid. The facility’s policy requires accurate posting and maintenance of direct care staffing levels, but the actual staffing did not match the scheduled levels during the shift when the fall occurred.
The facility failed to maintain and post current daily nurse staffing information at the front desk as required by its policy, leaving the posting unchanged for an extended period. Staff interviews revealed that the receptionist and DON understood the posting should be updated daily by the staffing coordinator, but it had not been updated due to the responsible person’s absence and miscommunication following a change in the scheduler position. The administrator acknowledged awareness that the posting had not been updated and confirmed that staffing levels, scheduled based on minimum required hours, were not being reflected on the daily staffing form, potentially affecting all residents in the facility.
A nurse failed to promptly document administration of scheduled morning medications on the eMAR for a resident who was bed bound, dependent on staff, and had multiple diagnoses including dysphagia, dementia, cerebral infarction, HTN, and major depressive disorder. The nurse acknowledged being late and not signing the medications at the time of administration, despite knowing they should sign as they administer. The resident had multiple ordered drugs, including cholecalciferol, clonidine, gabapentin, heparin, hydralazine with a BP hold parameter, and Keppra, and the care plan required medications to be given as ordered and monitored for side effects. Facility policy and the DON’s expectations required medications to be administered per practitioner orders and recorded promptly after each administration by the person who gave them.
A resident with type 2 DM had two unlabeled insulin pens and an unlabeled Acetaminophen 325 mg bottle stored on the bedside table, and reported currently self-administering Acetaminophen while no longer able to self-administer insulin due to hand weakness. Nursing staff stated that medications should not be left at bedside and that self-administration requires a physician order and assessment, yet record review showed no self-administration orders, no completed self-administration assessment, and no care plan interventions authorizing self-administration. This occurred despite facility policy requiring assessment, physician notification, an order to self-administer, and ongoing competency checks for any resident self-administering medications.
A resident with type 2 DM had two insulin pens (Lantus and Lispro) and an acetaminophen 325 mg bottle left on the bedside table, with no labeling for resident identification, date opened, or discard date. Staff interviews confirmed that medications should not be left at bedside and must be clearly labeled, and facility policy requires that any medications stored in a resident’s room be kept in a locked storage unit and documented on the MAR as "may keep at bedside." The observed practice did not comply with these requirements for safe medication storage and labeling.
Staff failed to follow the facility’s Enhanced Barrier Precautions (EBP) requirements when providing care to several residents with trachs, vents, G-tubes, urinary catheters, wounds, and histories of MDROs. A CNA repeatedly entered rooms with posted EBP signage and available PPE to reposition residents, change linens, and provide other direct care while wearing only gloves and a mask, without donning a gown as required. Multiple staff, including the wound director, RT, CNA, LPN, infection preventionist, and DON, stated that facility policy and expectations require gown, gloves, and mask for high-contact care and any direct contact with residents or their environment under EBP. Facility policies on Enhanced Barrier Precautions and the Infection Prevention and Control Program specify that gowns and gloves must be used for high-contact resident care activities and for all interactions that may involve contact with the resident or the resident’s environment, with PPE donned upon room entry and discarded before exit.
Broken Resident Toilet Not Addressed in Timely Manner: A resident reported a leaking, broken toilet that had not been resolved despite notifying housekeeping, maintenance, social work, and the administrator. Surveyors observed the toilet filthy, partially covered with a garbage bag, and filled with urine, while staff including the DON, LPN, maintenance director, and social service director acknowledged the issue and described miscommunication about ordering the replacement toilet.
A resident with severe cognitive impairment and high fall risk, requiring supervision for ambulation, was left unsupervised and without required safety alarms, resulting in an unwitnessed fall and hip fracture. Staff interviews and records showed that individualized fall prevention interventions, including frequent monitoring and use of alarms, were not consistently implemented as outlined in the care plan.
A resident with multiple medical conditions and under state guardianship was discharged without the required notification to their legal representative. Facility staff confirmed that the guardian was not informed of the discharge planning or arrangements, and there was no documentation of such notification, despite facility policy requiring it.
A resident with complex medical and psychiatric conditions alleged that another resident touched her inappropriately in a hallway. Although the resident stated she reported the incident to staff and police, the activity assistant and administrator were unaware of the allegation, and a social worker who learned of the incident did not report it, assuming others had done so. Facility policy requiring immediate reporting of abuse allegations was not followed.
Multiple residents at risk for skin impairment did not receive timely assessment, monitoring, or wound care as ordered, with failures to update care plans, notify families, follow physician orders for wound treatments, and adhere to low air loss mattress guidelines. Staff also failed to report new wounds, document care, and maintain proper medication management and infection control practices.
A facility failed to verify and obtain the correct state guardian information for a resident, resulting in improper notification and consent procedures. Despite discrepancies in contact information, the facility did not successfully contact the state guardian, and instead, the resident's family was notified and provided consent for medical decisions. Interviews revealed that the social services department did not follow through with obtaining necessary guardian paperwork or contact the main office of the state guardian.
The facility failed to administer enteral feedings as ordered for three residents, leading to issues such as weight loss and incorrect feeding formulas. A resident experienced a seven-pound weight loss due to an incorrect feeding rate, while another was given the wrong formula and rate. Additionally, a resident received enteral feeding while eating a meal, contrary to orders, risking fluid overload.
The facility failed to follow physician orders and manufacturer guidelines in managing pressure ulcers for several residents. Observations showed improper wound care and incorrect use of low air loss mattresses, with multiple layers of linen used instead of a single flat sheet. These deficiencies affected residents with stage 4 pressure ulcers, indicating a systemic issue in the facility's wound care management.
A resident in an LTC facility was not protected from unwelcome physical contact by another resident in an elevator, leading to a deficiency in the facility's abuse prevention program. The resident who reported the incident has a complex medical history and is on medication for anxiety and depression. The resident who initiated the contact has a history of criminal behavior and poor impulse control. Despite the facility's no-tolerance policy on abuse, the incident occurred, and a misdemeanor complaint was filed.
The facility failed to implement fall precautions for two high-risk residents. Observations revealed that one resident's bed was not in the lowest position, and floor mats were not in place, posing a fall risk. An LPN corrected the bed and mat placement. Another resident's floor mats were also not in place, and a CNA admitted to forgetting to replace them after care. The Restorative Nurse confirmed the residents' high fall risk and the need for interventions to prevent injuries.
A cognitively impaired resident at high risk for falls was not adequately monitored or provided with fall preventative measures, resulting in a preventable fall and subsequent hospitalization for a femur fracture. The facility failed to implement a comprehensive care plan or educate staff on fall risk precautions, leading to delayed identification and treatment of the injury.
A resident with severe cognitive impairment experienced inadequate pain management following an unwitnessed fall. Despite complaints of pain, the resident received only one dose of Tylenol, and no further pain assessments were conducted. The facility failed to adhere to its pain management policy, resulting in a delay in diagnosing a femur fracture that required surgical intervention.
The facility failed to properly operate pressure relieving air mattresses for four residents, leading to deficiencies in pressure ulcer prevention. A resident with multiple pressure ulcers was on a static mode mattress with incorrect weight settings, while three other residents were also observed on static mode mattresses, contrary to their care plans. The wound nurse confirmed that alternating pressure is necessary for effective wound healing.
A resident with cognitive impairment and multiple medical conditions experienced an unwitnessed fall, resulting in a serious hip fracture. The facility failed to report the incident to the IDPH within the required 24-hour timeframe, as mandated by their policy. The decision not to report was based on the interpretation of x-ray results suggesting an old fracture, despite the hospital confirming the injury and performing surgery. This represents a deficiency in adhering to reporting protocols for serious injuries.
A resident with multiple diagnoses, including urinary tract infection, had abnormal urinalysis results that were not promptly communicated to a physician. Despite the results being reviewed, there was a lack of communication between nursing staff during shift handoffs, leading to a delay in notifying the nurse practitioner. The facility's process for handling lab results was not followed, as the abnormal results were not documented in the resident's electronic medical record.
A resident with brittle Type 1 diabetes and seizure disorders did not receive prescribed insulin and anti-seizure medications, leading to a critical hospital transfer. The facility failed to document medication administration and lacked a care plan for the resident's seizure disorder. Interviews revealed inconsistencies in staff documentation and adherence to physician orders.
The facility failed to protect residents from abuse and prevent a physical assault in two separate incidents involving two residents. The first incident occurred in the activity room where an argument over a television program escalated, and one resident threw a Wii console at the other. Later, during a smoke break, the same resident physically assaulted the other with a wet floor sign. Staff intervened but failed to report the first incident immediately, and there was a lack of supervision.
The facility failed to follow dietary orders for two residents on NAS diets, resulting in inappropriate meal substitutions and inadequate nutrition. One resident received hamburgers without condiments daily, while another received a hamburger patty instead of the planned meal. Conflicting information from dietary staff and non-adherence to facility policies contributed to the deficiencies.
Failure to Implement Care-Planned Floor Mats for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement a care-planned fall prevention intervention of floor landing mats for a resident identified as high risk for falls. The resident is an alert and oriented individual with multiple diagnoses including COPD, atherosclerotic heart disease, chronic combined systolic and diastolic CHF, asthma, insomnia, epilepsy, Crohn’s disease, and muscle wasting and atrophy. The resident’s MDS shows a BIMS score of 14, and a Fall Risk Review assessment identifies the resident as high risk for falls. The care plan dated 12/08/22 documents that the resident is at high risk for falls with multiple contributing factors such as decreased strength and endurance, impaired gait and balance, seizure disorder, CHF, COPD, Crohn’s disease, G-tube, neuropathy, anxiety disorder, tachycardia, major depressive disorder, use of psychotropics, and enteral feeding, and includes an intervention initiated on 11/27/23 for floor landing mats when the resident is in bed. On 3/31/26, the resident experienced an unwitnessed fall from bed and was found lying supine on the floor, bleeding from the head, with a small laceration to the right side of the head; neuro checks and vital signs were within normal limits, and the resident remained alert and oriented. The resident reported that he must have rolled out of bed while asleep and stated that floor mats were not in place at the time of the fall. Multiple staff interviews provided conflicting accounts regarding the presence of floor mats, with two CNAs and an agency nurse stating they did not recall or did not see floor mats in place, while one CNA believed mats were present. The Administrator and the DON both confirmed that the resident did not have floor mats in place during the fall, and the DON stated that the resident should have had floor mats in place prior to the fall and that her expectation is for all staff to follow fall prevention interventions in residents’ care plans. The facility’s Falls Occurrence policy requires identification and evaluation of residents at risk for falls and implementation of individualized interventions and precautions to prevent or reduce injuries related to falls.
Failure to Maintain Scheduled CNA Staffing Linked to Resident Fall
Penalty
Summary
The facility failed to follow its staffing policy by not providing the scheduled number of certified nurse aides (CNAs) on a specific shift, which was associated with a fall experienced by a resident (R1). On the date in question, the second floor was normally staffed with three CNAs, but only two CNAs were present due to a last-minute call-off. The Director of Nursing (V2) confirmed that the unit was short-staffed compared to the posted schedule. Certified Nurse Aide V9 reported that the facility was short-staffed that day and that the nurse assigned to R1 was not on the floor when the fall occurred, only returning after 911 paramedics arrived. An agency nurse (V11) further stated that on that day the second floor had only two CNAs and that V11 was the nurse on the opposite side of the unit, not on R1’s side when the fall occurred. V11 reported that the nurse for R1 was not on the floor at the time of the fall, and that V11 was the one who called 911 and provided first aid to R1. The facility’s written policy on posting direct daily staffing numbers requires that staffing levels be posted for each shift and that the number and type of nursing personnel responsible for direct care be recorded and maintained, but the actual staffing on the unit did not match the scheduled or expected staffing level on the day of R1’s fall.
Failure to Maintain and Post Current Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to post accurate and current daily nurse staffing information as required by policy and regulation. On observation at the front desk, the daily staffing posting was found to have last been updated on 2/17/26, despite the requirement that it be updated every day for each shift. The receptionist reported that the posting had not been updated since that date and stated it should be updated daily, explaining that the person responsible for updating it had not been present. The Director of Nursing confirmed that the daily staffing hours should be posted each day by the staffing coordinator and was informed that the last posting was from 2/17/26. The Administrator stated that the facility schedules staff based on minimum required hours and that these staffing numbers should be reflected on the daily posting in the front area. The Administrator acknowledged awareness that the daily staffing posting had not been updated since 2/17/26 and attributed this to miscommunication regarding who was responsible for updating the posting after a change in the scheduler position, with the new scheduler being unaware of the responsibility. The facility’s written policy, revised 8/2008, requires that at the beginning of each shift the facility post the number and type of nursing personnel providing direct care, in a clear, readable format, in a prominent place accessible to residents and visitors, and that these records be maintained and available upon request. This policy was not followed, resulting in the absence of current daily staffing information for all shifts during the period reviewed, potentially affecting all 102 residents in the facility.
Failure to Promptly Document Medication Administration on eMAR
Penalty
Summary
Surveyors identified a deficiency in medication administration documentation for one resident when a nurse failed to sign the electronic medication administration record (eMAR) at the time medications were given. On 4/14/2026 at 12:40 p.m., a nurse (V12) was observed administering medications, and review of the eMAR showed that the 9:00 a.m. medications for resident R3 were not signed as administered. At 12:44 p.m., both the surveyor and V12 confirmed that the 9:00 a.m. medications remained unsigned. V12 stated that they had been running late that morning and did not have a chance to sign out R3’s medications, and acknowledged awareness of the expectation to sign medications as they are administered. Resident R3’s information indicated the resident was alert and oriented two to three with forgetfulness, bed bound, and dependent on staff, with diagnoses including dysphagia, cerebral infarction, dementia, hypertension, and major depressive disorder. An order summary dated 4/15/2026 listed multiple medications ordered for R3, including cholecalciferol, clonidine, gabapentin, heparin, hydralazine (with a hold parameter for systolic blood pressure below 110 mmHg), and Keppra, along with a care plan intervention to administer medications as ordered and monitor for side effects. Facility policy on medication administration required that drugs be administered in accordance with licensed practitioners’ orders and that medications be recorded on the medication record promptly after each administration by the individual who administered the drug. The DON (V2) stated an expectation that nurses sign out all medications as they are administered.
Failure to Implement Self-Administration Medication Policy and Control Bedside Medications
Penalty
Summary
The deficiency involves the facility’s failure to implement its self-administration of medication policy for a resident who had medications stored at bedside without appropriate orders or assessment. During observation, two unlabeled insulin pens (Lantus and Lispro) and an unlabeled bottle of Acetaminophen 325 mg were found on the resident’s bedside table. The resident reported that staff were aware of these medications being kept at bedside and stated that she was currently self-administering Acetaminophen/Tylenol, while also reporting that she was no longer able to self-administer insulin since returning from a recent hospitalization due to weakness in her hands. Review of the resident’s medical record showed diagnoses including type 2 diabetes mellitus without complications and active orders for Acetaminophen 325 mg every 6 hours as needed for pain, as well as scheduled Humalog (insulin lispro) before meals and Lantus (insulin glargine) at bedtime. Interviews with nursing staff confirmed that medications should not be left at bedside and that, if a resident is to self-administer medications, there must be a physician order and an assessment in place. The RN and the Assistant DON both stated that self-administration requires an order, an assessment, and care plan documentation. Record review with facility staff revealed there was no completed self-administration of medication assessment for this resident, no orders indicating self-administration for any medications, and the care plan only noted insulin use with an intervention to modify the care plan based on patient progress and needs. The facility’s written Self-Administration & Medication Storage Policy requires assessment of residents who request to self-administer, communication of assessment results to the attending physician, obtaining an order to self-administer, and quarterly or significant-change follow-up observations to determine continued competency, none of which were documented for this resident despite medications being present at bedside and the resident’s report of self-administering Acetaminophen.
Unlabeled Insulin and Acetaminophen Left Unsecured at Bedside
Penalty
Summary
Surveyors found that the facility failed to ensure medications were safely stored and properly labeled for one resident. During an observation at 11:00 AM, two insulin pens (Lantus and Lispro) and a bottle of acetaminophen 325 mg were observed sitting on top of the resident’s bedside table. The insulin pens and acetaminophen bottle were not labeled with any resident identification, date opened, or discard date. The resident stated that staff were aware that these medications were kept at the bedside. A review of the resident’s admission record showed diagnoses including type 2 diabetes mellitus without complications and active orders for acetaminophen 325 mg by mouth every 6 hours as needed for pain, Humalog KwikPen 8 units subcutaneously before meals, and Lantus 30 units subcutaneously at bedtime. At 11:20 AM, a registered nurse (V5) stated that medications should not be left at the bedside and should be labeled with the resident’s name, date opened, and discard date. At 11:23 AM, the assistant director of nursing (V3) similarly stated that medications should not be stored at the bedside and that medications should include clear labeling. Review of the facility’s “Self-Administration & Medication Storage Policy” (effective February 2014) showed that when medications are stored in a resident’s room, all medications, both legend and over-the-counter, must be stored in a locked storage unit, and all medications/biologicals stored in the resident’s room should be written on the MAR as “may keep at bedside.” These observations and statements demonstrated that the medications at the resident’s bedside were not stored in locked compartments and were not labeled in accordance with facility policy and accepted professional principles.
Failure to Use Required PPE for Residents on Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to staff failure to don required personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP). Four residents on EBP were involved: one with tracheostomy, ventilator dependence, gastrostomy tube, urinary catheter, and a history of carbapenem-resistant Acinetobacter baumannii; one with acute and chronic respiratory failure, ventilator dependence, pneumonia due to Klebsiella pneumoniae, tracheostomy, and gastrostomy; one with surgical aftercare needs and type 2 diabetes mellitus with complications; and one with tracheostomy, gastrostomy, cognitive communication deficit, multiple indwelling devices and wounds, and a known history of multiple multidrug-resistant organisms (MDROs) and C. difficile. All four residents were on EBP transmission-based protocols due to wounds, trachs, vents, G-tubes, urinary catheters, and/or MDRO history. On multiple observations on the same day, a CNA entered the rooms of these residents and provided direct care without wearing a gown, despite EBP signage and PPE supplies being present at the room entrances. For one resident, the CNA entered to reposition and assist without donning a gown, wearing only gloves and a mask, and had direct contact with the resident during care. After wound care for another resident, the same CNA again entered that resident’s room without a gown to reposition the resident, provide clean linens, and cover the resident with a blanket, then removed gloves and performed hand hygiene before leaving. The CNA was also observed entering another resident’s room on EBP to provide patient care, including changing linens, wearing only gloves and a mask and again not donning a gown, despite posted EBP signage and available PPE. Interviews with facility staff confirmed that the facility’s expectation and policy required staff to wear gowns, gloves, and masks when providing direct care to residents on EBP, including activities such as suctioning trachs, G-tube feedings, changing linens, changing diapers, and wound care. The wound director, respiratory therapist, CNA, LPN, infection preventionist, and DON each stated that for residents on EBP, staff must don gown, gloves, and mask for direct care or high-contact resident care activities. Facility policies titled “Enhanced Barrier Precautions” and “Infection Prevention and Control Program” specified that EBP involves the use of gown and gloves for high-contact resident care activities for residents colonized or infected with MDROs or at increased risk of MDRO acquisition, and that gowns and gloves are to be worn for all interactions that may involve contact with the resident or the resident’s environment, with PPE donned upon room entry and discarded before exiting. The observed failure of the CNA to wear gowns during direct care to residents on EBP occurred in the context of these established policies and stated staff expectations.
Broken Resident Toilet Not Addressed in Timely Manner
Penalty
Summary
The facility failed to follow its maintenance work orders policy by not providing a home-like environment and not implementing an effective remedy within the expected timeframe for a broken toilet in one resident’s room. The resident stated he notified housekeeping, maintenance, social work, and the administrator on October 6, 2025 that his toilet leaked when flushed, and he reported that the problem had still not been resolved when interviewed. On November 25, 2025, surveyors observed a broken toilet at the base of the manual flush valve with no handrails attached; the toilet bowl was more than half full of yellow urine, filthy, and partially covered with a transparent garbage bag. The resident stated he had tried covering the toilet bowl because of the odor. Interviews with facility staff showed awareness of the broken toilet and confusion about responsibility for repair. The social service director stated he was made aware of the issue on November 22, 2025, placed a work order, and notified maintenance; he also stated he spoke with the resident about a room change because the toilet was broken and not functioning, but the resident refused. An LPN stated she had known about the broken toilet for about 2 weeks and that the resident used the bathroom across the hall. The assistant administrator, DON, housekeeping director, maintenance director, and social service director all stated they were aware of the allegation, and the assistant administrator and maintenance director stated there was a miscommunication about ordering the toilet. Both the assistant administrator and social service director stated the toilet should have been fixed immediately.
Failure to Implement Fall Prevention Interventions for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to follow its fall prevention policy and implement individualized, resident-centered interventions for a cognitively impaired resident identified as high risk for falls. The resident, who had diagnoses including end stage renal disease, unsteadiness on feet, gait abnormalities, and atherosclerotic heart disease, was assessed as having severely impaired cognitive skills and required supervision or assistance when ambulating. Despite these documented needs, the resident was able to ambulate unsupervised, resulting in an unwitnessed fall in the hallway during the night. Staff interviews and record reviews revealed that the resident was confused, unable to use the call light, and required frequent redirection and monitoring. Care plans indicated the need for staff assistance with ambulation, use of electronic alarms, and regular monitoring. However, at the time of the incident, the resident did not have a chair or bed alarm in place, and staff monitoring was not conducted at the frequency specified in the care plan. The CNA on duty was the only staff present on the resident's wing and was not actively supervising the resident when the fall occurred. The fall resulted in the resident sustaining a right intertrochanteric hip fracture with associated intramuscular hemorrhage, requiring hospital admission. Documentation and staff statements confirmed that the facility did not consistently implement the individualized interventions outlined in the care plan, such as ensuring the use of alarms and providing the required level of supervision for a resident with significant cognitive impairment and high fall risk.
Failure to Notify Resident's Representative of Discharge Planning
Penalty
Summary
The facility failed to notify a resident's legal representative of discharge planning, orders, and arrangements for post-discharge care. The resident, who was cognitively intact and had multiple medical diagnoses including anemia, COPD, heart failure, substance abuse, and anxiety disorder, had been under state guardianship since 2022. Despite this, the state guardian was not informed of the resident's discharge or the details of the discharge planning. The guardian only learned of the discharge after sending an associate to visit the resident and did not receive any court documentation regarding the revocation of guardianship. Interviews with facility staff, including the Social Service Director and the Director of Nursing, confirmed that the guardian was not notified prior to the discharge. The Social Service Director admitted to not informing the guardian and acknowledged this was a mistake. Facility policy requires notification of the resident's representative regarding discharge planning, but there was no documentation in the resident's records indicating that such notification occurred.
Failure to Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to identify and report an allegation of sexual abuse involving a female resident with multiple medical and psychiatric diagnoses, including end stage renal disease, depression, and bipolar disorder. The resident reported that another resident touched her inappropriately while she was in her wheelchair in the hallway. She stated that she informed staff and the police, and provided a police report number to an activity assistant. However, the activity assistant denied receiving any such report or information from the resident, and the administrator, who also serves as the abuse prevention coordinator, stated that she was unaware of the incident until informed by the surveyor. A licensed clinical social worker, who had been providing services to the resident, documented that the resident discussed the incident and a police investigation during a session. The social worker assumed that the incident had already been reported to facility staff and did not take further action to notify the administrator or other responsible parties. Facility policy requires all employees to immediately report any allegations or suspicions of abuse to the administrator or designated personnel, but this protocol was not followed, resulting in the failure to report the allegation to the appropriate authorities in a timely manner.
Failure to Assess, Monitor, and Treat Wounds per Orders and Policy
Penalty
Summary
The facility failed to ensure ongoing assessment and monitoring for residents at risk for skin impairment, resulting in missed identification and documentation of new wounds, lack of timely physician notification, and failure to update care plans and notify family members. In one case, a resident with multiple comorbidities and high risk for skin breakdown developed new wounds that were not promptly addressed in the care plan, and the family was not informed of these changes. The wound care coordinator acknowledged that the care plan should have been updated and the family notified, but these actions were not taken at the time of the deficiency. There were also failures to follow physician orders for wound care treatments. For example, a resident with a stage 4 sacral pressure ulcer did not receive the correct type of dressing as ordered, with staff using gauze instead of foam dressings. Another resident with multiple wounds received foam dressings instead of the ordered gauze dressings, and a CNA failed to use proper PPE during wound care. These deviations from prescribed wound care protocols were confirmed by staff interviews and direct observation. Additionally, the facility did not adhere to manufacturer recommendations for the use of low air loss mattresses, as multiple layers of linen and blankets were placed between the resident and the mattress, contrary to guidelines. There were also lapses in medication management, such as wound care medications not being available on the treatment cart, use of another resident's medication, and leaving the treatment cart unlocked. New skin impairments were not reported to the nurse, and wound care documentation was incomplete or missing. These deficiencies affected all four residents reviewed for pressure ulcer and wound prevention and treatment management.
Failure to Verify and Notify State Guardian
Penalty
Summary
The facility failed to verify and obtain the correct state guardian information for a resident, leading to improper notification and consent procedures. The resident, who was admitted with diagnoses including respiratory failure, tracheostomy, dysphagia, and substance abuse, had a state guardian listed as the third contact on their face sheet. However, the admission paperwork indicated a different phone number for the state guardian. Despite this discrepancy, the facility did not successfully contact the state guardian, and instead, the resident's family was notified and provided consent for medical decisions. Interviews with facility staff revealed that the social services department did not follow through with obtaining the necessary guardian paperwork upon admission, nor did they contact the main office of the state guardian when initial contact attempts failed. The social service director acknowledged awareness of the issue but did not take further action to resolve it. As a result, the resident's family, rather than the state guardian, was contacted for consents and updates, which was against the facility's policy and procedures for handling residents with guardians.
Failure to Administer Enteral Feedings as Ordered
Penalty
Summary
The facility failed to administer enteral feedings as ordered for three residents, leading to significant issues. Resident R10 was observed with an enteral feeding running at 60 ml/hr, contrary to the physician's order of 65 ml/hr. This discrepancy was noted by a registered nurse who corrected the rate. R10, who is NPO and relies solely on tube feeding, experienced a weight loss of seven pounds over a month, which was attributed to the incorrect feeding rate. The nurse practitioner confirmed that the prescribed rate was necessary to prevent weight loss and provide the required nutrition and electrolytes. Resident R12 was found with an incorrect enteral feeding formula and rate, running Glucerna 1.5 at 70 ml/hr instead of the ordered Glucerna 1.2 at 80 ml/hr. The error was identified and corrected by a registered nurse, who noted that the night nurse had started the feeding incorrectly. Additionally, Resident R5 was receiving enteral feeding at 75 ml/hr while also consuming a meal, contrary to the physician's order to have the feeding off during the day. This oversight was acknowledged by a registered nurse, who admitted not knowing the feeding should have been stopped, potentially risking fluid overload for the resident.
Failure to Follow Wound Care Protocols and Mattress Guidelines
Penalty
Summary
The facility failed to adhere to physician orders and manufacturer recommendations in the management of pressure ulcers for multiple residents. Observations revealed that residents with stage 4 pressure ulcers were not provided with the appropriate wound care as per physician orders. For instance, a resident with multiple stage 4 pressure ulcers was observed to have wounds cleansed with Dakins solution and dressed with wet to dry Dakins dressing, contrary to the physician's order which specified the use of moist saline gauze after cleansing. Additionally, the resident was not provided with bilateral heel protectors as required by the care plan, and the low air loss mattress was improperly covered with multiple layers of linen, against manufacturer guidelines. The deficiency also extended to other residents who were observed with improper use of low air loss mattresses. Several residents were found with folded linens and additional bed pads over their mattresses, which contradicts the manufacturer's recommendation of using only one flat sheet. This improper use of the mattress could potentially compromise its effectiveness in preventing pressure ulcers. The facility's wound care nurse and other staff members acknowledged these discrepancies, indicating a lack of adherence to both physician orders and established care protocols. The facility's policies on wound care and specialty mattress use were not followed, as evidenced by the observations and interviews conducted. The facility's policy clearly states the need to follow physician orders and use specialty mattresses according to manufacturer guidelines, yet these were not implemented. The failure to follow these protocols affected all five residents reviewed for wound care management, highlighting a systemic issue in the facility's approach to pressure ulcer prevention and treatment.
Failure to Protect Resident from Unwelcome Physical Contact
Penalty
Summary
The facility failed to protect a resident from unwelcome physical touch by another resident, which constitutes a deficiency in their abuse prevention program. The incident involved two residents, where one resident allegedly touched the other's shoulder in an elevator. The resident who was touched later reported feeling uncomfortable, although no physical harm or skin alteration was noted. Both residents were evaluated at a hospital and returned to the facility without new orders. The facility conducted an investigation, and a misdemeanor complaint was filed against the resident who initiated the contact. The resident who reported the unwelcome touch has a complex medical history, including diagnoses of toxic encephalopathy, chronic respiratory failure, and end-stage renal disease, among others. She is also on medication for anxiety, depression, and bipolar disorder. The resident who allegedly initiated the contact has a history of criminal behavior and is identified as an offender with a behavior care plan indicating sexual preoccupation and poor impulse control. The facility's policy on abuse prevention emphasizes a no-tolerance approach to abuse, neglect, and exploitation, yet the incident highlights a failure to protect the resident from unwelcome physical contact.
Failure to Implement Fall Precautions for High-Risk Residents
Penalty
Summary
The facility failed to implement fall precaution interventions for two residents identified as high risk for falls. During an observation, one resident's bed was not in the lowest position, and the floor mats intended to prevent falls were not in place, instead leaning against a wall. The resident, who has a tracheostomy and is able to communicate, did not recall the last time they fell. A Licensed Practical Nurse (LPN) responsible for the resident acknowledged the oversight and corrected the bed position and floor mat placement, noting the potential risk of the resident falling and injuring themselves. Similarly, another resident was observed with their floor mats not in place, leaning against a radiator and wall. A Certified Nursing Assistant (CNA) responsible for the resident admitted to forgetting to replace the floor mats after providing care. The CNA corrected the oversight by placing the mats on both sides of the bed. The Restorative Nurse/Fall Coordinator confirmed that both residents are at high risk for falls and emphasized the importance of implementing fall precaution interventions to prevent potential injuries. The facility's policy on fall prevention and management outlines the necessity of such interventions to maintain resident safety.
Failure to Prevent Fall in High-Risk Resident
Penalty
Summary
The facility failed to adequately monitor and prevent a high-risk cognitively impaired resident from sustaining a preventable fall. The resident, identified as R57, had multiple diagnoses including End Stage Renal Disease, Major Depressive Disorder, and reduced mobility, and was assessed as being at high risk for falls. Despite this, the facility did not implement sufficient fall preventative measures or develop a comprehensive care plan tailored to the resident's needs. On the day of the incident, the resident was found on the floor by a maintenance technician who did not witness the fall but heard a loud thud. The resident was attempting to get out of bed unassisted, which led to the fall. The nursing staff's response to the fall was inadequate. The RN on duty, V8, assessed the resident without fully considering her severe cognitive impairment, and failed to complete the fall event form accurately. The RN did not verify the resident's fall risk status or ensure that appropriate interventions were in place. The resident was given Tylenol for pain, and an x-ray was ordered but not performed until the following day, delaying the identification of a significant injury. The resident was later diagnosed with a left femur fracture and required surgical intervention. Interviews with staff revealed a lack of awareness and training regarding fall risk precautions and interventions. The restorative director, V5, admitted that interventions were only put in place after a fall occurred, and there was no proactive approach to prevent falls for high-risk residents. The facility's fall prevention policy was not effectively implemented, as evidenced by the absence of necessary fall precautions and the failure to educate staff on identifying and protecting residents from falls.
Inadequate Pain Management for Cognitively Impaired Resident After Fall
Penalty
Summary
The facility failed to adequately recognize, evaluate, and manage pain for a resident with severe cognitive impairment following an unwitnessed fall. The resident, who had multiple diagnoses including End Stage Renal Disease and Major Depressive Disorder, experienced a fall and complained of pain. Despite this, the facility did not conduct timely pain assessments or provide adequate pain management. The resident was only given a single dose of Tylenol, and no further pain assessments or medications were administered until the resident was sent to the hospital two days later for a femur fracture requiring surgery. The nursing staff did not perform a thorough pain assessment following the fall. The nurse on duty did not ask the resident to indicate where the pain was or assess non-verbal indicators of pain, which is crucial given the resident's severe cognitive impairment. The nurse administered Tylenol based on a standing order but did not follow up with additional doses or assessments, despite the facility's policy requiring regular pain evaluations and management. The x-ray ordered to assess potential injuries was delayed, and the results were not communicated promptly, leading to a delay in the resident receiving appropriate medical intervention. The facility's policy on pain management was not adhered to, as evidenced by the lack of comprehensive pain assessments and timely interventions. The nurse practitioner involved was not informed of the x-ray results in a timely manner, and there was a lack of communication regarding the resident's pain management needs. This resulted in the resident experiencing unmanaged pain and a delay in receiving necessary medical treatment for a serious injury.
Improper Use of Pressure Relieving Mattresses
Penalty
Summary
The facility failed to properly operate and maintain pressure relieving air mattresses for four residents, leading to deficiencies in pressure ulcer prevention and management. Resident 54, who is cognitively impaired and has multiple pressure ulcers, was observed on a specialty air mattress set to static mode, which did not provide the necessary alternating pressure. Additionally, the mattress was under-inflated as the weight setting was incorrect, set at 80 lbs while the resident's weight was 103 lbs. This improper setting could potentially affect the healing of the resident's wounds. Similarly, residents 18, 41, and 121 were observed on low air mattresses in static mode, contrary to their care plans which required alternating pressure to prevent pressure ulcer development. Resident 18, with a history of chronic respiratory failure and quadriplegia, and resident 41, with hemiplegia and chronic kidney disease, were both observed in static mode on multiple occasions. Resident 121, who has a stage 4 sacral wound, was also found on a static mode mattress, which was not in line with the prescribed care for his condition. The wound nurse confirmed that alternating pressure is necessary for effective wound healing and that incorrect mattress settings can hinder this process.
Failure to Report Serious Injury from Unwitnessed Fall
Penalty
Summary
The facility failed to adhere to its policy on incident reporting within twenty-four hours of an unwitnessed fall that resulted in serious harm to a resident, identified as R57. The resident, who is cognitively impaired and has multiple medical conditions including End Stage Renal Disease and Major Depressive Disorder, experienced a fall while attempting to sit on the side of the bed. The fall was unwitnessed, and the resident complained of pain in both thighs. An x-ray was ordered, and the results, which indicated a fracture, were received the following day. Despite the serious nature of the injury, the facility did not report the incident to the Illinois Department of Public Health (IDPH) within the required timeframe. The facility's investigation into the fall concluded that it was accidental, and the decision not to report the incident was made collectively by the Administrator, the Restorative Nurse, the President of Operations, and the Infection Preventionist. They based their decision on the x-ray results, which suggested the fracture might be old or healing. However, the hospital's evaluation confirmed the fracture, leading to surgical intervention for the resident. The facility's policy mandates that incidents resulting in serious harm or injury be reported to IDPH within 24 hours, with a final summary completed within 7 days, which was not followed in this case. The resident was subsequently hospitalized with a diagnosis of a closed fracture of the left hip and underwent a Left Hip Arthroplasty. The facility's failure to report the incident in a timely manner represents a deficiency in following established protocols for reporting serious injuries. The decision not to report was influenced by the interpretation of the x-ray results and the belief that the fracture was not new, despite the hospital's findings and the subsequent surgery.
Failure to Notify Physician of Abnormal Urinalysis Results
Penalty
Summary
The facility failed to notify a physician of abnormal urinalysis results in a timely manner for a resident, identified as R125, who was admitted with diagnoses including hemiplegia, heart failure, retention of urine, and urinary tract infection. On observation, the resident's urine appeared dark yellow and slightly cloudy. A registered nurse, V6, acknowledged that the urinalysis was completed weeks prior due to the resident's complaints of burning upon urination, and an antibiotic was ordered based on the abnormal results. However, V6 admitted to not checking the urine results on the day of the survey until prompted by the surveyor, at which point it was confirmed that the results were abnormal and required notification to the nurse practitioner. Another registered nurse, V18, who worked with the resident the previous day, was unaware of the pending urinalysis due to a lack of communication during the handoff report. V18 stated that results are typically checked multiple times during a shift, but no results for the resident were seen before the end of the shift. The surveyor noted discrepancies in the reported date and review status of the lab results, indicating that the abnormal results were reviewed but not communicated to the physician. The Director of Nursing explained the process for handling lab results, emphasizing the importance of notifying the physician of abnormal results and documenting them in the resident's electronic medical record, which was not done in this case.
Failure to Administer Medications and Document Care for Diabetic Resident
Penalty
Summary
The facility failed to provide appropriate medical management for a resident with brittle Type 1 diabetes and a history of seizure disorders. The resident, who was admitted with multiple complex medical conditions including Type 1 Diabetes Mellitus, seizures, and end-stage renal disease, did not receive insulin and anti-seizure medications as prescribed. On June 8, 2024, the resident's insulin was not administered according to the physician's orders, and there was no documentation of blood glucose monitoring. Additionally, the resident's anti-seizure medication, Dilantin, was not administered as ordered on June 7, 2024, which was confirmed by the LPN responsible for the medication pass. The resident experienced a seizure and elevated blood glucose levels, leading to an emergency transfer to the hospital. The resident's blood glucose was recorded at 573, and the Dilantin level was critically low at 4.0, far below the reference range. The resident was hospitalized with severe hyperglycemia and dehydration, which contributed to a hyperosmolar hyperglycemic state and metabolic acidosis. The facility's failure to administer medications as prescribed and to document these actions resulted in the resident's critical condition and subsequent hospitalization. Interviews with facility staff revealed inconsistencies in medication administration and documentation. The LPNs involved admitted to potential errors in documenting the administration of insulin and anti-seizure medications. Furthermore, there was no care plan in place for managing the resident's seizure disorder, which is a critical oversight given the resident's medical history. The Director of Nursing acknowledged that the nurses should have followed the physician's orders and documented all medication administrations, highlighting a significant lapse in the facility's adherence to its medication administration and care planning policies.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse and prevent a physical assault in two separate incidents involving two residents, R5 and R6. The first incident occurred in the activity room where R6, who was watching television, got into an argument with R5 over the television program. The argument escalated, and R6 threw a Wii console at R5. Staff intervened and separated the residents, but the incident was not reported to the administrator or nursing staff immediately. Later, during a smoke break, R6 went to the first floor and heard R5 threatening to press charges. R6 then grabbed a wet floor sign and physically assaulted R5 with it. Staff intervened again, and both residents were separated and assessed for injuries. R5 had no visible injuries, and R6 was sent for a psychiatric evaluation but returned to the facility a few hours later with no new orders. R5's medical records indicate a history of generalized anxiety disorder, muscle weakness, hypertension, encephalopathy, heart failure, gait and mobility abnormalities, and a personal history of cocaine abuse. R5 was cognitively intact and had a care plan that included a potential for abuse. R5 reported the incidents to staff but felt that nothing was done about it. R6's medical records indicate a history of encephalopathy, hypertension, opioid use with withdrawal, depression, and psychoactive substance abuse. R6 had a history of verbally aggressive behavior towards staff and difficulty controlling his temper. R6's care plan did not include any orders for managing his anger or aggression. The facility's abuse prevention policy requires staff to report any incidents of abuse immediately and to protect residents from abuse, neglect, exploitation, and mistreatment. However, the staff failed to report the first incident involving the thrown console to the administrator or nursing staff, and there was a lack of supervision in the activity room and during smoke breaks. The administrator acknowledged that R6's actions were willful and that there should have been more supervision. The facility has a system in place to train staff on abuse reporting and prevention, but it was not effectively implemented in this case.
Failure to Follow Dietary Orders for Residents on NAS Diets
Penalty
Summary
The facility failed to provide adequate nutrition by not following dietary orders for two residents. One resident, a male with intact cognition, was on a No Salt Packet (NAS) diet and reported receiving hamburgers without condiments seven days a week, despite his dietary restrictions and preferences. Another resident, a female with severely impaired cognition, was observed receiving a hamburger patty on a bun instead of the planned meal of baked turkey crunch, rice pilaf, and vegetable medley, as indicated on her meal ticket. The dietary staff confirmed that the substitution was made based on their judgment rather than the resident's request or dietary order. The Dietary Director and Cook both provided conflicting information regarding the NAS diet and the reasons for meal substitutions. The Dietary Director stated that NAS diet residents should receive the same meals without additional salt packets, while the Cook indicated that certain meals, like the baked turkey crunch, were substituted due to high salt content. The facility's policies on sodium precautions and menu substitutions were not followed, leading to the observed deficiencies in meal service for the residents on NAS diets.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,576 citations issued within 25 miles in the last 12 months — including the 30 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Des Plaines
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avantara Park Ridge | 0.8 mi | ★★★★★ | 0 | 0 |
| Niles Nsg & Rehab Ctr | 1.3 mi | ★★★★★ | 3 | 0 |
| Elevate Care Niles | 1.4 mi | ★★★★★ | 10 | 0 |
| Harmony Park Ridge | 1.5 mi | ★★★★★ | 6 | 0 |
| Park Ridge Healthcare Center | 1.8 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.