Bethany Rehab: Broken Collarbone Left Untreated - IL
The X-ray, when it finally came back on July 28, showed an acute displaced fracture of the left clavicle.
The fall happened on July 26, 2025, at 10:12 PM. A progress note from that night documented that the resident, identified in inspection records as R60, had fallen from her chair and was complaining of left shoulder pain. Staff ordered an X-ray — but scheduled it for Monday, two days away.
Nobody called to check on its status. Nobody ordered a sling.
By July 27, R60 had visible bruising on her left shoulder and limited range of motion in her left arm. Staff gave her pain medication. The sling order did not exist yet, and the X-ray still had not been done. The fracture, displaced and potentially dangerous, went unconfirmed for another full day.
The previous Director of Nursing, interviewed by inspectors on September 2, said she had been notified of the fall the night it happened. She did not begin her investigation until Monday morning, July 28, when she also called radiology because the X-ray team still hadn't come. She acknowledged the original nurse on duty had not placed a stat order and had not followed up to ensure the imaging was completed or a sling was obtained. "Just because [R60] is on hospice doesn't mean we don't treat people," she told inspectors.
That line landed in the inspection report without elaboration, but it answered a question nobody had asked aloud: whether the resident's hospice status had shaped how urgently staff responded.
A nurse practitioner reviewed the case on September 4 and was direct. She said that given the fall and the immediate complaint of pain, the X-ray order should have been entered as a stat order — meaning immediately — and completed within 24 hours. "They shouldn't have waited until Monday. That's a delay of care," she told inspectors. She noted that with a displaced fracture, the concern is not merely pain management. A displaced clavicle fracture can puncture surrounding structures. Knowing the nature of the fracture, and knowing it quickly, matters.
The nurse practitioner also confirmed that while R60 had pain medication already on board, the sling was not ordered until after the X-ray results came back on July 28. That means R60 spent at least 36 hours after the fall with an unprotected, unsupported fractured shoulder.
"Based on R60's injury there isn't much they can do for her," the nurse practitioner said, noting the care would be conservative given R60's condition. But she was clear: timely imaging was still essential. The fracture's displacement made that urgent regardless of prognosis.
Federal inspectors classified this deficiency as causing actual harm. The inspection was conducted on September 5, 2025, following a complaint.
R60 fell on a Saturday. The nurse assigned to her care that night did not order imaging as an emergency. The X-ray did not happen until Monday. The sling did not come until after the results. For the hours in between, she had bruising, limited movement, and a broken bone that nobody had formally identified.
The former Director of Nursing said it herself: she shouldn't have had to wait that long.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bethany Rehab & Hcc from 2025-09-05 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: June 30, 2026 · Our methodology
BETHANY REHAB & HCC in DEKALB, IL was cited for violations during a health inspection on September 5, 2025.
The X-ray, when it finally came back on July 28, showed an acute displaced fracture of the left clavicle.
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.