Bethany Rehab: Call Light Failures, Hygiene Neglect - IL
Those are among the findings from a September 2025 complaint inspection at Bethany Rehab & Health Care Center, a nursing facility at 3298 Resource Parkway in DeKalb.
A resident identified in inspection records as R28 told the surveyor she hadn't had a bed bath in three to four weeks when inspectors visited on September 2. Her hair was greasy. Her skin was dry and flaking. She said she had refused a bath the previous week because she wasn't feeling well, and after that, staff never came back to try again.
"My skin gets itchy and I just feel gross," she said.
R28's care records documented that she needs substantial to maximal assistance with bathing and is dependent for toilet hygiene. She can't do this herself. She told the surveyor that call lights can take a while depending on who's working, and that a week and a half before the inspection she waited an hour and a half.
"I really had to poop. It was awful," she said. "I think they have a problem here with staffing. I can control my bowel and bladder pretty good, but sometimes the wait is too long, and I have an accident. That's really embarrassing."
She also described a pattern with agency staff specifically. They would come in at 9 p.m. to get her ready for the night, she said, and she might not see anyone again until morning. Some agency CNAs, she said, would come in, turn off her call light, tell her they'd be back, and disappear.
A second resident, R11, told inspectors on September 2 that last month he waited 85 minutes for his call light to be answered. He soiled himself. His records show he also needs substantial to maximal assistance for bathing and toilet hygiene.
When inspectors returned to speak with R11 two days later, he had more to say. His call light had been broken for six or seven days, he said, and he'd been given a hand bell to use instead. He was waiting an average of 50 to 60 minutes every time he rang it.
"They need more staff here to help answer the call lights," he said.
A CNA who left the facility on July 26, about five weeks before the inspection, confirmed the picture both residents described. She said there were days when they were short-staffed and couldn't get to call lights in time, couldn't finish showers, couldn't deliver meals on schedule. "It could be overwhelming at times," she said. On short days, she said, staff tried to keep residents safe and dry. When staffing improved, they tried to catch up on what they had missed.
"There were definitely residents that had to wait for us to get incontinence care," she said. "We'd try to work together and just go from one end of the hall to the other."
The facility's scheduler told inspectors she sets four nurses and six aides on day shift, three nurses and seven aides on second shift, and two nurses and four aides overnight. She said the daytime and evening ratio runs one aide to eight residents. Overnight, it's one aide to sixteen. She said she had never been made aware of a call off that wasn't covered and was not aware of any staffing issues.
The Regional Director of Operations, interviewed September 4, said the facility has no policy for call light use or response time.
The Assistant Director of Nursing, interviewed the same afternoon, said her expectation is that any staff member in the building should answer a call light and that it should be addressed within three to five minutes.
There is no policy requiring that. There is only the expectation.
R28 said the facility has some really good CNAs. She made that clear. But she also said they use a lot of agency staff, and the agency staff are the ones who turn off the light and don't come back.
She was lying in bed when the surveyor found her on September 2. Greasy hair. Dry, flaking skin. Three to four weeks since her last bath, by her own count, with one refusal in the middle that nobody followed up on.
"You don't want to know," she told the surveyor, when asked how long it had been.
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: 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: September 24, 2026 · Our methodology
BETHANY REHAB & HCC in DEKALB, IL was cited for neglect violations during a health inspection on September 5, 2025.
A resident identified in inspection records as R28 told the surveyor she hadn't had a bed bath in three to four weeks when inspectors visited on September 2.
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.