Rivaya Care of Des Plaines: Fall Prevention Failure - IL
The fall happened at approximately 1:30 AM. Nobody saw it.
Federal inspectors cited Rivaya Care on September 29, 2025, following a complaint investigation. The citation carries a finding of actual harm, meaning the failure caused real injury to a real person, not a theoretical risk. The resident is identified in inspection records only as R1.
R1 had been admitted on September 11, 2025. His admission evaluation documented gait disturbance and unsteady gait. He used a wheelchair. His care plan identified him as a fall risk and listed specific interventions, including an electronic alarm for his bed or chair. The alarm was never activated.
The Director of Nursing described him plainly on September 25: "He is a fall risk. He came from the hospital because of a fall." She said he was alert but inconsistent, able to hold a conversation but unable to retain information, requiring redirection from staff. "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."
That last sentence carries the weight of the whole citation. The electronic alarm existed precisely to prevent an unwitnessed fall. It was in the care plan. It was not used.
Progress notes from September 11 described R1 as alert and oriented to self, eating breakfast, denying pain, but with "noted confusion, requiring redirection per staff." The Nurse Practitioner who examined him told inspectors he was "confused with place and time, he has dementia, able to verbalize needs." She said she had never seen him walk. "He sits in the wheelchair. I am a fall risk," she said of his status. Her recommendations after the fall included making sure the bed was locked, the wheelchair was locked, that he wore non-skid socks, and that staff follow fall protocol.
Those were the things that should have already been happening.
The facility's own Falls Guideline, dated August 2024, lays out an explicit process: identify residents at risk, evaluate them, implement individualized interventions, monitor, analyze. It states that residents evaluated as fall risks will have individualized precautions developed and that preventative measures shall be taken. It calls for an interdisciplinary team approach. It names cognitive status as a factor in fall risk evaluation.
R1's cognitive status was not a mystery. His confusion was documented the day he arrived. His history of falling was the reason he was there. His care plan named the electronic alarm as a required intervention. The gap between what the paperwork required and what staff actually did was not a matter of clinical judgment. The alarm was simply not turned on.
The care plan interventions that were in place focused on educating R1, reminding him to use his call light, and encouraging him to ask for help. The Director of Nursing acknowledged he is confused and forgetful. The Nurse Practitioner said he has dementia and is confused about place and time. A care plan built around a man remembering to ask for help, for a man who cannot reliably remember where he is, is not a fall prevention plan. It is a document.
R1 got up at 1:30 in the morning. He found his walker. He walked. His legs gave out. No alarm sounded. No one came.
The inspection report does not describe the injuries he sustained when he fell. It does not say whether he lay on the floor before anyone found him, or for how long. What it says is that the harm was actual, not potential, and that the interventions his care team had already identified as necessary for his safety had not been carried out.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rivaya Care of Des Plaines from 2025-09-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 26, 2026 · Our methodology
RIVAYA CARE OF DES PLAINES in DES PLAINES, IL was cited for violations during a health inspection on September 29, 2025.
The fall happened at approximately 1:30 AM.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.