Ascension Nazarethville: Accident Hazard Failures - IL
The social services director, identified in inspection records as V2, acknowledged all of this himself when inspectors arrived on December 31, 2025. He said he had not completed the abuse and neglect assessment for the resident, referred to in the report as R1. He said he had not documented the refusals. He said no assessment had been done following the allegation of abuse, following the bruising incident, or following the significant change in condition recorded in early November. He said it plainly, without apparent dispute.
That conversation happened at 12:04 in the afternoon. By 1:30, the facility's administrator had told inspectors something that made the gap in oversight harder to explain away: the facility had no policy on resident safety or prevention of injury. Inspectors asked for it. The facility could not produce one.
The inspection was a complaint investigation. The report does not describe who filed the complaint or what prompted it, but what inspectors found when they arrived painted a picture of a facility that had, for months, failed to follow through on the most basic protective obligations toward at least one resident who had already been hurt.
R1's situation had not been invisible. The resident had protective devices in place, Geri sleeves and padded siderails, suggesting a documented vulnerability to injury. A family member, identified as V3, had declined an abuse assessment during the annual review attempt in August 2025. That refusal was never written down. The social services director said the last time he had tried to complete the annual assessment, dated to August 15, V3 had refused. He did not record it.
When a family member declines a protective assessment, that decision belongs in the record. The reason matters. The date matters. Whether anyone followed up matters. None of it was there.
Then came the bruising. The report describes it as an incident of bruising from an unknown injury. No date is given for when the bruising appeared. What is clear is that an allegation of abuse followed, and that after both the bruising and the allegation, no abuse assessment was completed. The facility's own abuse prevention policy, revised as recently as August 2025, stated that the objective was to comply with a seven-step approach to abuse and neglect detection and prevention. One of those steps involves ongoing assessment of residents whose needs or behaviors may lead to conflict or neglect. Another involves monitoring staff on all shifts for inappropriate behavior toward residents.
The policy existed on paper. The practice did not follow it.
By November 3, R1's condition had changed significantly enough that the facility completed what is called an MDS significant change assessment, a formal clinical review triggered when a resident's status shifts in a meaningful way. An abuse assessment is supposed to correspond with that review. None was done.
The administrator, identified as V1, told inspectors at 1:30 that afternoon that staff should document any refusal of an abuse assessment. That is not a policy position being articulated for the first time. It is an acknowledgment that the standard existed and was not followed. V1 also confirmed the facility had no resident safety or injury prevention policy. Inspectors noted the facility was unable to provide one.
The care planning policy the facility did have, revised in October 2021, described a system in which assessments are ongoing and care plans are revised as a resident's condition changes. Whether that system was functioning for R1 is not addressed in the inspection report. What is addressed is the three-month window between August and December during which the most basic abuse-related documentation was absent.
Facilities that serve residents with cognitive or physical vulnerabilities rely on the abuse assessment process as a detection mechanism. When a resident cannot reliably describe what happened to them, the assessment is often the only systematic way to identify whether abuse or neglect contributed to an injury. Geri sleeves are typically used to protect fragile skin from bruising or tearing. Their presence in R1's care plan signals that someone had already recognized the resident's skin as a concern. The bruises that appeared afterward, from an unknown cause, made the absence of any follow-up assessment more consequential, not less.
The social services director's candor with inspectors on December 31 was notable. He did not claim the assessments had been completed and misfiled. He did not suggest the documentation existed somewhere else. He said directly that he had not done them and had not recorded the refusal. That kind of straightforward admission is useful in an inspection but does not change what it describes: a resident who had been injured, whose family had declined a protective review, and who had experienced a significant health change, all without the facility completing a single abuse assessment across any of those three triggering events.
The facility's abuse prevention policy named the resident and family group council as a partner in developing, monitoring, and evaluating the abuse prevention program. It described a commitment to involving that group in oversight. Whether the council knew that R1's assessments had gone undone for months is not something the inspection report addresses.
The violations were cited at a level of harm described as minimal harm or potential for actual harm, affecting few residents. That classification reflects the regulatory language, not necessarily the experience of R1, a resident with unexplained bruises, protective equipment already in place, and months of missed assessments behind them.
The report ends there. The inspection was completed. The findings were recorded. What happens next for R1, and whether the abuse assessment that should have been done in August, October, and November has since been completed, the report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ascension Nazarethville Place from 2025-12-31 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: August 5, 2026 · Our methodology
ASCENSION NAZARETHVILLE PLACE in DES PLAINES, IL was cited for violations during a health inspection on December 31, 2025.
The social services director, identified in inspection records as V2, acknowledged all of this himself when inspectors arrived on December 31, 2025.
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.