Ascension Nazarethville Place: Abuse Assessment Failures - IL
The resident, identified in inspection records only as R1, lives at Ascension Nazarethville Place, a nursing facility at 300 North River Road in Des Plaines. She carries diagnoses of dementia, psychosis, depression, and anxiety. She prefers to stay in her room. Staff described her as prone to verbal resistance and behavioral aggression, and noted she can become agitated and swing her arms.
On December 24, 2025, during the 3-to-11 shift, a certified nursing assistant observed bruising on R1's right wrist and forearm. The registered nurse on duty, identified as V6, measured the injuries: a bruise on the right wrist measuring 4 centimeters by 3 centimeters, and a bruise on the right forearm measuring 2 centimeters by 2 centimeters. R1 denied pain. V6 notified the primary care physician, ordered an x-ray of R1's right hand, and called a family member, identified as V3, who was herself a resident in another unit of the same facility.
Around 9 that night, V3 called the police. She believed the bruises were the result of abuse. An officer arrived around 10 p.m. and conducted an investigation.
V6 told inspectors she believed R1's bruising was related to anticoagulant medication, which can make bruising more likely, combined with R1's behavioral patterns. She said R1 sometimes swings her arms when agitated and can strike hard objects. The facility had previously used Geri sleeves — padded protective coverings for the arms — but R1 had refused them. V6 said they also used a Broda chair, a padded reclining wheelchair, and placed pillows on each side of R1's bed for protection.
What inspectors found when they looked more closely didn't match that description. R1 was observed that day using a high-back wheelchair that was not padded. Her room contained only two pillows. A CNA identified as V5 told inspectors that those two pillows were placed under R1's head, not along the sides of the bed as protection. V6 acknowledged that devices like Geri sleeves, padded side rails, and pillows along the sides of the bed were options for protecting R1 from injury.
Nobody had documented the refusal of Geri sleeves. Nobody had updated R1's abuse care plan after the December 24 incident.
The Christmas Eve bruising was not the first incident. Inspectors found that an abuse allegation had also been made in October 2025. No abuse assessment was completed after that incident either. A significant change in condition recorded in R1's MDS assessment, dated November 3, 2025, also should have triggered an abuse assessment under the facility's own policies. It did not.
The social services director, identified as V2, told inspectors on December 31 at 12:04 p.m. that he had not completed an abuse and neglect assessment. The last time he had attempted one was August 15, 2025, when V3, the family member, declined to participate. V2 said he did not document that refusal — not V3's refusal, and not R1's. The administrator, identified as V1, acknowledged that any refusal should have been documented, and that an abuse assessment should follow each allegation and each relevant change in condition.
No abuse assessment exists for R1 for any point in 2025.
The facility's own abuse prevention policy, revised in August 2025, states that residents have the right to be free from abuse, neglect, and mistreatment, and commits the facility to identifying, assessing, care planning, and monitoring residents with behaviors that may lead to conflict or neglect. The policy calls for implementing preventive measures. It describes a seven-step approach to abuse detection and prevention.
None of those steps were applied to R1 after October. None were applied after November 3. None were applied after December 24.
When inspectors asked the administrator about a separate but related gap — whether the facility had a policy on resident safety and injury prevention — V1 said at 1:30 p.m. on December 31 that no such policy existed.
The inspection was a complaint investigation. It was completed December 31, 2025, the same day inspectors were gathering these admissions from staff. The findings were classified as actual harm or potential for actual harm, affecting a limited number of residents.
What the record shows is a woman with dementia, living in a facility that acknowledged she was at risk of injuring herself, whose protective measures weren't consistently in place, whose family called the police on Christmas Eve because she had unexplained bruises, and whose care team had gone an entire year without completing the assessment designed to determine whether she was being abused or neglected.
The social services director knew, in August, that the annual assessment hadn't been done. He didn't document the family's refusal. He didn't attempt another approach. He didn't complete it after October's allegation. He didn't complete it after November's change-in-condition note. He told inspectors on December 31 that it still wasn't done.
V3, the family member who called police on Christmas Eve, is herself a resident at the same facility, living in a different unit. She visited R1 after being notified of the bruises. She was the one who decided, around 9 p.m. on Christmas Eve, that what she saw warranted a call to law enforcement.
The x-ray results are not included in the inspection report. What happened after the police officer completed his investigation is not recorded. Whether the bruises were ever explained is not stated.
R1 was observed on New Year's Eve in an unpadded wheelchair, with two pillows on her bed that a staff member confirmed were used only under her head.
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: 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: August 17, 2026 · Our methodology
ASCENSION NAZARETHVILLE PLACE in DES PLAINES, IL was cited for abuse-related violations during a health inspection on December 31, 2025.
The resident, identified in inspection records only as R1, lives at Ascension Nazarethville Place, a nursing facility at 300 North River Road in Des Plaines.
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.