Average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Asbury Court Nursing & Rehab during CMS and state inspections, most recent first.
A resident who was cognitively intact and managed her own finances discovered that a check for $1800 had been cashed without her consent and another check was missing after returning from PT and reviewing her bank statement. She reported this to her CNA, who confirmed the check had been present earlier and notified facility leadership. An agency CNA was identified as having worked on the unit on the days the unauthorized check was cashed and the second check went missing, and that CNA’s belongings were later found hidden in an empty room containing financial items from residents in other states. This occurred despite a facility policy intended to prevent abuse, neglect, exploitation, and misappropriation of resident property.
A resident with moderate cognitive impairment, care planned as dependent on a mechanical lift for all transfers, was transferred by a CNA using a mechanical lift without the required second staff member and without the proper sling. During the transfer, the CNA reported the lift was not working correctly, lowered the bed, and proceeded alone; both shoulder slings broke when the resident was about two feet above the bed, causing a fall and head impact on the lift. An RN and the DON confirmed that at least two staff were required by facility policy for mechanical lift transfers and that this requirement was not followed, resulting in a head laceration that required staples in the emergency department.
A resident with dementia was not protected from sexual abuse by another resident with Alzheimer's and poor impulse control. The male resident was observed inappropriately touching the female resident, who was not alert. Staff intervened immediately, and the incident was reported to authorities. The facility's abuse policy defines such contact as non-consensual, indicating a failure to protect the resident.
A resident with a history of dementia and repeated falls experienced seven falls in one month, resulting in a subdural hematoma and head laceration. Despite being at high risk and requiring maximum assistance, the resident was left unattended in the bathroom, leading to a fall. Staff interviews confirmed the resident's need for constant supervision, which was not provided, violating the facility's fall prevention policy.
A cognitively impaired male resident in an LTC facility was observed by a CNA engaging in inappropriate contact with a severely cognitively impaired female resident. The male resident has a history of such behavior towards the female resident, possibly due to a perceived relationship. The female resident's daughter, who is her POA, was aware of her mother's past behavior and had consented to limited physical contact under supervision, but stated her mother cannot give consent. The facility lacked a system to prevent such incidents.
A resident with severe cognitive impairment due to dementia physically abused two other residents, causing injuries. The incident occurred in the dining room, where staff were present but unable to prevent the altercation. The aggressive behavior was linked to a UTI, but the facility's failure to prevent the abuse was noted as a deficiency.
A resident on hospice care with Parkinson's Disease and Dementia received an incorrect dose of Hydromorphone due to a medication administration error. The RN involved claimed to have documented the dose incorrectly, but the DON confirmed the wrong dose was given. The error was discovered through a NARC sheet review, and the resident experienced no side effects.
The facility failed to monitor and record dishwasher temperatures correctly, as observed during a kitchen tour. The dish machine log showed no recorded temperatures for several days, and attempts to check the temperature using a sensor label were unsuccessful, indicating a potential issue. Interviews with staff confirmed that daily temperature recording is required, and the facility's policy mandates maintaining dish machine water temperature per manufacturer's recommendations.
The facility failed to properly store nebulizer masks for two residents, as required by its policy. Observations revealed that a resident's nebulizer mask was left uncovered on a bedside counter, while another's was stored without a covering in a drawer. Both an LPN and the DON confirmed that the masks should be covered when not in use, in accordance with the facility's policy.
Failure to Protect Resident From Misappropriation of Financial Property
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when a staff member allegedly accessed and used the resident’s financial instruments without consent. One cognitively intact resident with a BIMS score of 15, who independently manages her own finances and keeps her checkbooks in her room, discovered that a check for $1800 had been cashed without her authorization and that another check was missing. The resident reported this to her CNA after returning from physical therapy and reviewing her bank statement. The CNA confirmed that the resident had the missing check before leaving for therapy and, after being informed of the unauthorized transaction and missing check, notified the nurse and then the Administrator. During the facility’s review, it was identified that an agency CNA had worked on the unit on the day the $1800 check was cashed and again on the day the second check went missing. The Administrator reported that this CNA had only worked twice in the facility and that, during a police investigation, the CNA initially claimed to have no belongings in the building. However, the CNA’s belongings were later found stored in an empty room instead of the staff break area, and those belongings contained resident financial items from other states. The facility’s abuse, neglect, and exploitation policy defines misappropriation of resident property as the wrongful use of a resident’s belongings or money without consent and states that the facility will implement policies and procedures, including appropriate staffing and training, to prevent such misappropriation; despite this, a resident’s checks were accessed and used without consent while under the facility’s care and supervision.
Single-Staff Mechanical Lift Transfer Leads to Resident Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to follow its Safe Resident Handling/Transfers policy requiring two staff members for mechanical lift transfers. A resident with moderate cognitive impairment, documented as dependent on a mechanical lift for all bed-to-chair transfers, was being transferred by a CNA using a mechanical lift without a second staff member present. The resident’s MDS indicated dependence for transfers, and the care plan specified use of a mechanical lift for all transfers. During a busy morning, after providing a sponge bath, the CNA placed a sling under the resident and attempted to use the mechanical lift alone. While performing the transfer, the CNA reported that the lift was not working properly, so the bed was lowered to its lowest position to make it work with the resident. As the resident was lifted, both shoulder slings broke when the resident was approximately two feet above the ground, causing the resident to fall and hit her head on the lift. The nurse who assessed the resident noted minor head bleeding and pain, and the resident was sent to the hospital where a head laceration required five staples. The RN, the resident’s nurse, and the DON each confirmed in interviews that the CNA transferred the resident alone with a mechanical lift, contrary to the facility policy that two staff members must be utilized when transferring residents with a mechanical lift, and that the CNA did not use the proper sling.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident. The incident involved a female resident with dementia and cognitive impairments, who was not alert, and a male resident with Alzheimer's disease, depression, and poor impulse control. The male resident, who was alert but had impaired judgment, was observed acting inappropriately towards the female resident in a hallway. A nurse's aide witnessed the male resident reaching under the female resident's sweater, and the nurse intervened immediately to stop the incident. The male resident admitted to the inappropriate behavior but could not explain why he did it. The facility's Director of Nursing and other staff were informed of the incident, and the male resident was placed on one-to-one observation. The police, doctor, family, and facility administration were notified. The male resident was sent to behavioral health, and measures were taken to prevent further incidents. The facility's abuse policy defines sexual abuse as non-consensual contact of any type with a resident, highlighting the deficiency in protecting the female resident from such abuse.
Failure to Prevent Falls in High-Risk Resident
Penalty
Summary
The facility failed to ensure the safety of a resident, resulting in multiple falls and injuries. The resident, an elderly female with a history of dementia, type II diabetes, repeated falls, and other conditions, experienced seven falls within a month. These incidents included a fall on 11/27/24, where she was found on a floormat next to her bed and sustained a traumatic subdural hematoma and a head laceration requiring sutures. Another significant fall occurred on 12/2/24, when the resident was left unattended in the bathroom by a CNA who went to seek assistance. Upon returning, the resident had fallen and was diagnosed with a subdural hematoma at the hospital. Interviews with staff revealed that the resident was known to be at high risk for falls and required maximum assistance with toileting. Despite this, the resident was left alone in the bathroom, contrary to the facility's fall prevention policy, which mandates individualized care and supervision based on each resident's risk factors. The facility's Co-Director of Nursing acknowledged the resident's high fall risk and the need for constant interventions to prevent falls, highlighting a lapse in adherence to the established fall prevention protocols.
Inadequate Prevention of Inappropriate Resident Interaction
Penalty
Summary
The facility failed to implement a system to prevent inappropriate sexual actions by a cognitively impaired male resident towards a female resident. An incident occurred where a Certified Nurse's Aide (CNA) witnessed the male resident placing his hand in the female resident's brief in the dining room. The female resident did not appear or verbalize any distress at the time. The male resident, who has mild cognitive impairment, could not recall the incident when questioned later. The female resident, who has severe cognitive impairment, was not present during the investigation as she was hospitalized for unrelated reasons. The incident report and interviews with staff revealed that the male resident had a history of touching the female resident but not others, possibly due to a perceived relationship. The female resident's daughter, who is her Power of Attorney, was aware of her mother's past behavior and had consented to limited physical contact under supervision. However, the daughter stated that her mother is not capable of giving consent, and the facility had agreed to a non-sexual companion relationship for her mother. The incident highlights a deficiency in the facility's system to protect residents from inappropriate actions by others.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent a resident from physically abusing two other residents, leading to a deficiency in protecting residents from abuse. The incident involved a male resident with severe cognitive impairment due to dementia, who exhibited aggressive behavior towards two female residents. The male resident, identified as R1, was reported to have hit one female resident, R2, causing redness on her neck, and another female resident, R3, resulting in a skin tear on her forearm. This behavior was not typical for R1, who was later diagnosed with a urinary tract infection (UTI) that may have contributed to his aggression. The incident occurred in the dining room, where staff were present but unable to prevent the altercation. R2 reported being hit by R1, and R3 attempted to intervene, resulting in her injury. Staff responded by separating the residents and sending R1 to the hospital for evaluation. The hospital records confirmed R1's aggressive behavior and the presence of a UTI. Despite the staff's intervention, the facility's failure to prevent the initial abuse and protect the residents from harm was noted as a deficiency. The facility's abuse policy outlines procedures for preventing and identifying abuse, including staff training and monitoring residents with behaviors that might lead to conflict. However, the policy's implementation was insufficient in this case, as the aggressive incident occurred despite staff presence. The facility's response included notifying relevant parties and providing medical assessments for the affected residents, but the deficiency highlights a lapse in the facility's ability to prevent resident-to-resident abuse.
Significant Medication Error in Hospice Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in a resident receiving an incorrect dose of Hydromorphone. The resident, an elderly male with medical diagnoses including Parkinson's Disease, Dementia, repeated falls, and low back pain, was on hospice care. On a specific date, the resident was administered 1ml of Hydromorphone instead of the prescribed 0.25ml. This error was identified through a review of the NARC sheet, which revealed the discrepancy in the medication administration. The RN involved in the incident claimed to have administered the correct dose but documented it incorrectly. However, the Director of Nursing confirmed that the RN administered an incorrect dose, which was initially due to a miswritten order. The facility's Medication Administration policy emphasizes the importance of following the six rights of medication administration, which include the right dosage and documentation. Despite the error, the resident did not experience any side effects, and the issue was only discovered after reviewing the NARC count.
Dishwasher Temperature Monitoring Deficiency
Penalty
Summary
The facility failed to correctly monitor and record the dishwasher temperature, which is essential for ensuring the sanitation of dishware, service ware, and utensils. During a kitchen tour, it was observed that the dish machine log lacked recorded temperatures from July 18th to July 23rd, 2024. The Food Service Director (V3) attempted to check the dishwasher temperature using a recommended sensor label, but the label did not change color as expected, indicating a potential issue with the dishwasher's temperature. The Area Manager (V4) also conducted a temperature check with the same result. Interviews with V3 and V4 revealed that the temperature should be recorded daily and that the sensor label should turn black if the correct temperature is reached. The facility's policy requires that dish machine water temperature be maintained according to the manufacturer's recommendations and that temperature or sanitizer concentration logs be completed as appropriate.
Improper Storage of Nebulizer Masks
Penalty
Summary
The facility failed to adhere to its policy regarding the proper storage of nebulizer masks for two residents, R24 and R39, out of a sample of 24. On multiple occasions, surveyors observed R24's nebulizer mask left uncovered on the bedside counter and R39's nebulizer mask stored without a covering inside a drawer. A Licensed Practical Nurse (LPN) acknowledged that the nebulizer masks should be covered when not in use, as per the facility's policy. The Director of Nursing (DON) also confirmed that the nebulizer mask should be stored in a zip lock bag once dry, according to the facility's revised policy on nebulizer therapy from May 2023.
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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.
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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) |
|---|---|---|---|---|
| Elevate Care Des Plaines | 2.2 mi | ★★★★★ | 4 | 0 |
| Lee Manor | 2.4 mi | ★★★★★ | 1 | 0 |
| Alden Des Plaines Rehab & Hc | 3.2 mi | ★★★★★ | 4 | 0 |
| Moorings Of Arlington Heights | 3.3 mi | ★★★★★ | 0 | 0 |
| Ascension Nazarethville Place | 3.5 mi | ★★★★★ | 3 | 0 |
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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.