Bethany Rehab: Wound Care Infection Failures - IL
The inspection captured the wound care procedure in real time. The nurse, identified in the report as V11, was treating a resident's wound that required a piece of black foam placed directly into the wound bed, then sealed with strips of clear silicone adhesive drape. To cut both the foam and the drape to size, V11 used the same pair of scissors throughout. Between cuts, she set the scissors on the resident's bed linens. She did not sanitize them before cutting the foam that would go directly into the wound. She did not sanitize them between opening supply packages and touching wound materials. Inspectors watched the entire procedure and documented that at no point did V11 place the scissors on a clean or sterile surface.
The facility's own Assistant Director of Nursing, who also serves as the Infection Preventionist, confirmed during an interview the following afternoon that what V11 had done was wrong. On multiple counts.
"Scissors should not be placed on a resident's bed linens because they are considered 'dirty,'" the Assistant Director of Nursing said on September 4, 2025, "and should be placed on a clean/sterile area to prevent wound infections." She said V11 should either have sanitized the scissors before cutting the black foam or used a separate pair entirely. She also said V11 should have performed hand hygiene between glove changes, particularly given the complexity of the wound being treated.
The wound in question belonged to a different resident from the one whose care was directly observed, identified in the report as R7, described as having a complex wound. The Assistant Director of Nursing said the standard of care for a wound like that demands a higher level of infection control, not a lower one.
She was also asked about something else: performing wound care in conditions of inadequate pest control. Her answer was direct. "It could worsen the resident's wound or cause a wound infection," she said.
The inspection report does not elaborate on the pest control issue beyond that single statement. What prompted the question, what the pest problem involved, and how long it had existed are not detailed in the narrative. But the fact that the facility's own infection officer was asked about it, and answered it as a wound care risk, is in the record.
The violation was cited at a level of minimal harm or potential for actual harm, and inspectors noted that many residents were affected, a designation that reflects scope rather than the severity level assigned to any individual case.
What the inspection captured was not a documentation failure or a policy gap on paper. It was a nurse, observed in the act, handling wound care supplies in a way that her own facility's infection control officer said created real risk of infection or reinfection for a resident with an open wound. The scissors moved from bed linens to supply packages to foam that was pressed directly into the wound. Nobody stopped it.
The resident whose wound received that foam and those adhesive strips, identified only as R11, is not described further in the report. Their wound type, their overall condition, and whether they later developed an infection are not recorded in this document.
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 violations during a health inspection on September 5, 2025.
The inspection captured the wound care procedure in real time.
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.