Bethany Rehab: Hygiene and Incontinence Care Failures - IL
The resident, identified in inspection records as R28, had been a patient at the facility for years. Her care plan, in place since January 2022, spelled out her situation plainly: bladder incontinence driven by impaired mobility and diuretic medication, total dependence on staff to get to the toilet, and a preference for bed baths once a week on Wednesdays, given by specific aides she trusted. She wore disposable briefs and was supposed to be changed every two hours and whenever she needed it.
What inspectors found in her records told a different story.
On August 13, there was no entry at all for her shower. On August 20, the record showed the activity simply did not occur. There was no note in her progress records showing she had refused. There was no shower sheet for either date. Two consecutive Wednesdays, and nothing to show anyone had tried.
The facility's own Assistant Director of Nursing described what should have been happening. Speaking to inspectors on September 4, she said CNAs are expected to check residents every two hours because "you never know when they have to go." She said there is no reason incontinence care should not happen at night. She said sitting in urine or feces can cause infection and skin breakdown. She said residents should receive a minimum of two showers a week, that hygiene matters for infection prevention, and that if a resident refuses, the aide is supposed to notify a nurse, try again later, and contact family if the resident still declines. All of that, she said, should be documented in the electronic medical record.
None of it was documented for R28 on those dates.
The assistant director was direct about what poor hygiene does to a person. Hair gets greasy. Skin becomes dry and flaky. There is itching. For a woman who is totally dependent on staff to move her, to use the toilet, to bathe, those are not abstract possibilities. They are the predictable result of being left without care.
The inspection classified the violation under the federal tag governing personal hygiene and grooming, with a finding of minimal harm or potential for actual harm affecting a small number of residents. That classification sits at the lower end of the federal harm scale. It does not mean nothing happened. It means inspectors could not confirm, from the records in front of them, that something worse had already occurred.
What the records did confirm is that R28's care plan called for weekly bathing on a set day with aides she specifically requested, and that on at least two of those days in August 2025, no one documented that it happened. Her incontinence care, which her plan required every two hours around the clock, had no documented nighttime checks to show inspectors.
The August 6 entry showed she had received her shower and needed physical help. That entry existed. The next two did not.
For a resident whose care plan had been in place for more than three years, the expectations were not new or complicated. The facility's own nursing leadership could recite them without hesitation when asked. The documentation simply was not there.
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 resident, identified in inspection records as R28, had been a patient at the facility for years.
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.