Rivaya Care of Des Plaines: Fall Alarm Never Activated - IL
The resident, identified in inspection records only as R1, came to the facility in September 2025 with a documented history of falls, gait disturbance, and unsteady gait. His admission evaluation noted he used a wheelchair. His care plan listed an electronic alarm as a required precaution. It was not implemented.
At 1:30 in the morning, he got up and walked. His legs gave out.
The Director of Nursing described it plainly during an interview with inspectors on September 25th. "He is a fall risk. He came from the hospital because of a fall." She said he could hold a conversation and verbalize his needs but struggled with memory and detailed thinking, requiring redirection from staff. Because the fall happened in the middle of the night with no one present, she said, he could not be redirected in time.
The facility's nurse practitioner told inspectors she had never personally seen the resident walk. "He sits in the wheelchair," she said. "I have not seen him walk. He is a fall risk." She listed what should have been happening: regular rounds, locked bed, locked wheelchair, non-skid socks, fall protocol followed.
None of it mattered if the alarm that was supposed to alert staff he was moving was never switched on.
Rivaya Care's own fall prevention policy, dated August 2024, requires individualized precautions for every resident identified as a fall risk, implemented at admission and revisited with any significant change in condition. A patient arriving directly from a hospital stay caused by a fall, with documented dementia and an unsteady gait, meets that threshold without ambiguity.
The inspection, triggered by a complaint, found the lapse caused actual harm. The man had already fallen once before he arrived. He fell again, alone, in the dark, because a piece of equipment that might have summoned help was sitting unused beside his bed.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
RIVAYA CARE OF DES PLAINES in DES PLAINES, IL was cited for violations during a health inspection on September 29, 2025.
His admission evaluation noted he used a wheelchair.
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.