Bethany Rehab & Hcc
BETHANY REHAB & HCC in DEKALB, IL — inspection on September 5, 2025.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
there a shower sheet for 8/13 or 8/20.)
of functional and urge incontinence related to impaired mobility and diuretic use.
The interventions
Plan initiated 1/24/22 showed she has an ADL (Activity of Daily Living) self-care deficit and prefers bed bath once a week to be given by specific CNAs per her request.
The interventions showed she required assistance of 1 staff for weekly bed bath on Wednesday.
The interventions showed she totally dependent on staff for the use of the toilet.
On 9/4/25 at 11:35 AM, V2 (Assistant Director of Nursing – ADON) said the CNAs should be checking on our residents every 2 hours because you never know when they have to go.
There is no reason why incontinence care shouldn't be provided at night. V2 said if a resident has to sit in urine or feces, they could develop an infection and have led to skin breakdown. V2 said the facility wants to provide residents with dignity and ADL care is an important part. V2 said the residents should be getting a minimum of 2 showers a week. V2 said it is important for adequate hygiene and prevention of infections. V2 said the CNAs (Certified Nursing Aides) should be documenting the showers in the task portion of the EMR (Electronic Medical Record). If a resident refuses, then the CNA should notify the nurse, and I would expect to see the refusal in the progress notes. V2 said if a resident refuses a shower, then the staff should try to come back later and they still reuse, then we need to notify their family. V2 said if residents aren't getting showers their hair could get greasy; skin can become dry and flaky; and they may experience itchiness.
145958 09/05/2025
Bethany Rehab & Hcc 3298 Resource Parkway Dekalb, IL 60115
pain from a fall on 7/26/25.
These orders showed an order for an external splint to left shoulder if
left shoulder pain during assessment and an X-ray was ordered for Monday. (2 days later).
The notes showed did not show evidence that the facility called to check the status of the Xray. R60's progress notes on 7/27/25 showed R60 was experiencing pain, had bruising to the left shoulder, and had limited range of motion to the left arm.
These notes showed that R60 was treated for pain, but did not have the sling in place, nor had the Xray been completed. On 7/28/25, R60's X-ray results were reported to the physician and orders for a sling were obtained for additional support.
R60's Left Shoulder Xray Report dated 7/28/25 showed an acute displaced fracture of the left clavicle.
On 9/2/25 at 2:01 PM, V15 (previous Director of Nursing – DON) said she was notified R60 fell out of her chair on 7/26/25. V15 said she did the investigation on Monday (7/28/25) and she called X-ray to follow-up because they hadn't come yet for the Xray. V15 said the Xray order was placed for Monday and R60 shouldn't have had to wait that long. V15 said V18 (Agency RN) didn't place a stat order, and they didn't ensure the X-ray was completed or the sling order was obtained in a timely manner. V15 stated, “Just because [R60] is on hospice doesn't mean we don't treat people.
On 9/4/25 at 10:40 AM, V14 (Nurse Practitioner) said she wasn't here when R60 fell, but if she fell directly on her left side and complained of pain an X-ray order should have been entered to be done immediately.
They shouldn't have waited until Monday.
That's a delay of care. V14 reviewed R60's chart and said she already had pain medication on board, but it looks like the sling wasn't ordered until after the Xray results. V14 said the facility should have ensured Xray was ordered immediately, completed within 24 hours, and the interventions were placed. V14 said it's important to make sure the fracture isn't displaced or puncturing something. V14 said based on R60's injury there isn't much they can do for her. V14 said R60's care would be more conservative, but it was important to get the Xray results timely.
The facility's policy and procedure approved 12/2024 showed, “Fluid Restriction, Policy: Only those resident's that have a practitioner's order will be on fluid restriction.
Procedure: 1.
Verify medical practitioner order. 2.
Notify dietary consultant of order for fluid restriction… 3.
Remove the resident's water pitcher and cup from the room.
Store in designated area…”
145958 09/05/2025
Bethany Rehab & Hcc 3298 Resource Parkway Dekalb, IL 60115
[ROOM NUMBER]-A was on for 69 minutes. R1's face sheet documented admission date of
her skin appeared dry and flaking. R28 said she prefers bed baths and was supposed to get them
know. R28 said it's been 3-4 weeks since her last bed bath but did state that she refused last week because she wasn't feeling well. R28 said that was the only time she refused, and they didn't come try again. R28 said her skin gets itchy and she just feels gross. R28 said the call lights can take a while to get answered. R28 said it really depends on who is working. R28 said it can take a couple minutes, but a week and half ago she waited 1.5 hours. R28 stated, I really had to poop. It was awful. 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. R28 said another problem is they might come in at 9:00 PM to change me for the night and I might not see anyone again until morning. R28 said the facility does have some really good CNAs, but they also use a lot of agency staff. R28 said some of the agency CNAs will come in, turn off my call light, say they will be back, but they never come back. R28 said there definitely doesn't seem to be enough staff. R28's facility assessment dated [DATE] showed she was cognitively intact; required substantial to maximal assistance for shower/bathing and was dependent for toilet hygiene. On 09/02/2025 at 12:37 PM, R11 stated that last month he wanted 85 minutes for his call light to be answered by staff that caused him to soil himself. R11's facility assessment dated [DATE] showed he was cognitively intact; required substantial to maximal assistance for shower/bathing and for toilet hygiene.On 09/03/2025 at 2:32 PM, V26 (Scheduler) said she schedules four nurses and six aides on day shift, three nurses and seven aides on second shift, and two nurses with four aides on third shift during the week and on weekends. V26 added that the staff to patient ration on days and second shift is 1:8, and 1:16 on third shift. V26 indicated that when a call off occurs, they communicate the opening one staffing agency and a mass text is sent through on-shift for in-house staff to be inform of availability.
V26 then said there has never been a time when a call off was not covered and she was not made aware of any staffing issues. On 09/04/2025 at 8:38 AM, V9 (Certified Nursing Assistant-CNA) said she no longer works at the facility and 7/26/25 was her last day. V9 said she worked full-time days and floated around the facility. V9 said there were days when they were short staffed and they would have difficulty delivering meals on time, getting to call lights in a timely manner, completing showers/bed baths, and obtaining weights. V9 said it could be overwhelming at times. V9 said on the days they were short staffed they just did their best to keep the residents safe and dry.
Then if we had a day with more staff, then we would try to make up for some of the things we missed.
There were definitely residents that had to wait for us to get incontinence care. We'd try to work together and just go from one end of the hall to the other.On 09/04/2025 at 12:43 PM, V6 (Regional Director of Operations) said the facility has no policy for call light use or response time.On 09/04/2025 at 01:15 PM, V2 (Assistant Director of Nursing) said, we staff to meet the needs of the residents and are staffed based on the census and acuity of care, her expectation is for any staff member in building to answer a call light to see what the issue is, and the call light should be answered within 3-5 minutes then provide the resident with a timeframe to assist with their needs if helping another resident.On 09/04/2025 at 01:18 PM, R11 said he had to use a bell for the last 6-7 days while call light was being repaired and had to wait an average of 50-60 minutes every time he rang the bell for staff to respond.
R11 then said, they need more staff here to help answer the call lights.
Undated Resident Grievance Process policy provided by facility reads in part: it is the intent of each community to encourage residents, their representatives or family members, opportunities to communicate any concerns, suggestions, complaints, or opportunities for improvement in care or services.
145958 09/05/2025
Bethany Rehab & Hcc 3298 Resource Parkway Dekalb, IL 60115
(Centers for Medicare and Medicaid) 671 form dated 9/2/2025 shows there are 68 residents in the
AM on 9/2/2025, V4 [NAME] was observed adding rice to the pork and rice casserole that was on the steam table. V4 said he needed to use another pan to make enough rice for the casserole. V4 stirred the casserole to combine the new rice added.
The temperature was checked the casserole was served to the residents. At 1:00 PM, the rice casserole was tasted by the surveyor, and no flavor could be tasted, the meat was tough to chew, and the rice was clumped and stuck together.
There was no color to the dish.On 9/2/2025 at 1:02 PM, V4 said when he made the casserole, he did not have all the ingredients and did not put in the celery and lemon juice. V4 said he tries to add some flavor to the food but has been told by management not to do this.On 9/2/2025 at 1:06 PM, V3 Dietary Manager said the lemon juice and celery was not ordered and could not be used in the recipe. V3 said the residents deserve to have food that tastes good and if they do not like a certain recipe it should be replaced on the menu.On 9/3/2025 at 10:30 AM, during the resident group meeting , the residents (R8, R13, R50, R66) reported the food often lacks flavor.
The resident said there is an alternate menu but they are getting tired of hamburgers and hot dogs.
The residents said they have complained about the food many times, but do not feel they are being listened to.A review of the facility grievance logs shows on 5/22/2025, R13 complained about her meal stating, I cannot describe what was given to me on my plate to this noon.
The most disgusting piece of chicken I've ever seen. I wouldn't give it a dog.The resident council meeting minutes for the last 6 months were reviewed and showed numerous complaints of the food not tasting good enough to eat.The recipe for the pork and rice casserole provided by the facility shows celery and lemon juice were to be added.
145958 09/05/2025
Bethany Rehab & Hcc 3298 Resource Parkway Dekalb, IL 60115
to cut the clear, silicone adhesive drape into strips.
After V11 had cut several strips of drape, she
drape. At no time did this surveyor observe V11 place the scissors on a clean surface or sanitize the
foam that is placed directly on the wound.
On 09/04/2025 at 1:00 PM, V2 (Assistant Director of Nursing & Infection Preventionist) said V11 should have performed hand hygiene between glove changes to prevent infection and/or reinfection especially when working with a complex wound as R7's. V2 then said scissors should not be placed on a resident's bed linens because they are considered “dirty” and should be placed on a clean/sterile area to prevent wound infections. V2 added that V11 should not have cut the black foam with scissors that were not sanitized or V11 should have used a separate pair of scissors to cut the foam. At 1:10 PM, V2 said regarding performing wound care with inadequate pest control, “it could worsen the resident's wound or cause a wound infection.”
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.