Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Ascension Nazarethville Place during CMS and state inspections, most recent first.
A resident with dementia, behavioral issues, and on anticoagulant therapy was found with unexplained bruises on multiple occasions. Despite repeated allegations of abuse by a family member, staff did not consistently complete or document required abuse/neglect assessments or update the care plan after incidents. Protective interventions were inconsistently applied and not always documented, and the facility lacked a specific policy on resident safety and injury prevention.
A resident with dementia, behavioral issues, and on anticoagulant therapy experienced repeated bruising without the facility updating the care plan or implementing new interventions to prevent further injury. Staff did not consistently use protective devices, and required assessments and documentation were not completed after incidents or allegations. Family concerns about possible abuse were reported multiple times, but no new measures were put in place to address the resident's ongoing risk.
A resident who was alert and able to communicate requested assistance from a CNA to be changed and returned to bed, but the CNA refused, stating it was too much work. The resident did not receive peri-care during that shift and was only assisted by the next shift CNA after further requests. Facility investigation confirmed that the CNA willfully withheld care, resulting in substantiated neglect.
A surveyor found an expired Lantus Kwikpen on a medication cart, which had been used for a resident. The insulin pen, which should have been discarded after 28 days, was still in use. The RN on duty disposed of the expired pen after confirming its recent use. The DON stated that nurses are educated on insulin administration, and the facility's policy requires labeling insulin pens with opening and discard dates. Despite these measures, the expired insulin was not removed from the cart.
Failure to Implement Abuse Prevention Policies and Complete Required Assessments
Penalty
Summary
The facility failed to implement its policies and procedures to prohibit and prevent abuse, specifically in the case of a resident with multiple medical conditions including dementia, Parkinson's disease, atrial fibrillation (on anticoagulant therapy), and behavioral issues such as agitation and physical aggression. The resident was found with unexplained bruises on multiple occasions, and the family member repeatedly raised concerns about possible abuse. Despite these incidents, the facility did not consistently complete or document required abuse/neglect assessments after each allegation or incident of bruising, nor did they update the abuse care plan following new allegations. Observations and interviews revealed that the resident was prone to bruising due to her medication and behavioral tendencies, such as swinging her arms and resisting care, which could result in accidental injury. Staff acknowledged the use of protective devices like Geri sleeves and padded chairs, but there was inconsistency in their application and documentation. For example, the resident sometimes refused protective devices, but refusals were not documented, and staff could not confirm consistent use of interventions intended to prevent injury. Record review showed that the facility's abuse prevention policy required ongoing assessment, care planning, and monitoring of residents at risk for abuse or neglect. However, there was no evidence of completed abuse/neglect assessments for the resident in 2025, including after significant changes in condition or following allegations of abuse. The facility also lacked a specific policy on resident safety and prevention of injury, and failed to document refusals of assessments or update care plans as required by their own procedures.
Failure to Update Care Plan and Provide Adequate Supervision for Resident with Recurrent Bruising
Penalty
Summary
A deficiency was identified when the facility failed to provide adequate supervision and develop new care plan interventions to prevent injury and bruising for a resident with a known history of injury and bruising. The resident, who has multiple diagnoses including Parkinson's disease, atrial fibrillation (on anticoagulant therapy), dementia, and behavioral issues such as agitation and resistance to care, was observed with fading bruises on her right hand and forearm. Staff interviews revealed that the resident is prone to swinging her arms and hitting hard objects during episodes of agitation, which, combined with her blood thinning medication, increases her risk for bruising. Despite this, protective devices such as Geri sleeves or padded side rails were not consistently used, and staff acknowledged that interventions to prevent further injury were not implemented. Family members repeatedly raised concerns about the resident's bruising, suspecting abuse, and reported these concerns to the state health department. The facility's administrator and staff confirmed that incidents of unexplained bruising had occurred previously, and that the care plan had not been updated to address these recurring injuries. There was no documentation of new interventions or interdisciplinary team meetings to address the resident's ongoing risk for injury, nor was there evidence of regular skin assessments as required by the care plan for residents on anticoagulants. Additionally, the facility lacked a specific policy on resident safety and prevention of injury. Record review further showed that abuse/neglect assessments were not completed after each incident or allegation, and refusals of assessment by the resident or family were not documented. The last care plan conference with the family occurred months prior, and there was no follow-up after multiple allegations of abuse. The facility's own policies require ongoing assessment and care plan revision as resident conditions change, but these were not followed in this case, resulting in a failure to ensure adequate supervision and protection from injury for the resident.
Neglect Due to Failure to Provide Peri-Care
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) failed to provide peri-care to a resident who was alert, oriented, and able to communicate her needs. The resident requested to be changed and to return to bed, but the CNA refused, stating it was too much work and that once the resident was back in bed, she would not be assisted further. As a result, the resident's peri-care was not performed during the CNA's shift and was only completed by the next shift CNA after the resident called for assistance. The facility's administrator and social service director confirmed that the CNA willfully withheld care, and the facility's investigation substantiated neglect. The resident reported the incident to facility leadership, and documentation showed that the CNA admitted to not performing peri-care checks during her shift, without providing a reason. Facility policy requires peri-care checks every two hours or more frequently if needed. The failure to provide timely care and the CNA's response to the resident's request led to the substantiated finding of neglect for this resident.
Expired Insulin Pen Administered to Resident
Penalty
Summary
The facility failed to monitor and dispose of expired insulin medication according to its policy and manufacturer recommendations. During an observation, a surveyor found an expired Lantus Kwikpen on the 2nd Floor Middle Cart, which had been used for a resident identified as R63. The insulin pen was supposed to be discarded after 28 days of opening, but it was still in use. The Registered Nurse (RN) on duty, V5, acknowledged the oversight and disposed of the expired pen in the presence of the surveyor. The RN confirmed that the expired insulin had been administered to R63 the previous night. The Director of Nursing (DON), V2, stated that nurses are educated on insulin administration and are aware that insulin pens should be discarded after a specified period. The facility's policy requires pharmacy to label insulin pens with the date of opening and the discard date. Despite these measures, the expired insulin was not removed from the medication cart. The DON reported that R63's vitals and blood glucose levels were normal, and the resident did not report any issues after receiving the expired insulin. The facility conducts monthly audits of medication carts, and shift nurses are expected to check for expiring medications.
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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) |
|---|---|---|---|---|
| Alden Des Plaines Rehab & Hc | 0.3 mi | ★★★★★ | 4 | 0 |
| Lee Manor | 1.9 mi | ★★★★★ | 1 | 0 |
| Rivaya Care Of Des Plaines | 1.9 mi | ★★★★★ | 9 | 0 |
| Elevate Care Abington | 2.2 mi | ★★★★★ | 1 | 0 |
| Elevate Care Des Plaines | 2.5 mi | ★★★★★ | 4 | 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.