Bethany Rehab & Hcc

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

8/6/25 and required physical help. There was no entry for 8/13/25. On 8/20/25 it showed the activity itself did not occur. (Resident R28's Progress notes did not contain a note regarding resident refusal, nor was there a shower sheet for 8/13 or 8/20.) Resident R28's Care Plan initiated 1/24/22 showed Resident R28 had bladder incontinence and demonstrates symptoms of functional and urge incontinence related to impaired mobility and diuretic use. The interventions showed Resident R28 used disposable briefs and should be changed every 2 hours and as needed. Resident R28's Care 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.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bethany Rehab & Hcc

3298 Resource Parkway Dekalb, IL 60115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684

pain from a fall on 7/26/25. These orders showed an order for an external splint to left shoulder if pain noted was entered 7/28/25.

Level of Harm - Actual harm Residents Affected - Few

Resident R60's Progress Note dated 7/26/25 at 10:12 PM showed Resident R60 fell out of her chair and complained of 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. Resident R60's progress notes on 7/27/25 showed Resident R60 was experiencing pain, had bruising to the left shoulder, and had limited range of motion to the left arm. These notes showed that Resident R60 was treated for pain, but did not have the sling in place, nor had the Xray been completed. On 7/28/25, Resident R60's X-ray results were reported to the physician and orders for a sling were obtained for additional support. Resident 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 Resident 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 Resident 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 [Resident 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 Resident 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 Resident 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 Resident R60's injury there isn't much they can do for her. V14 said Resident 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…”

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bethany Rehab & Hcc

3298 Resource Parkway Dekalb, IL 60115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

if helping another resident.On 09/04/2025 at 01:18 PM, Resident 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. Resident 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bethany Rehab & Hcc

3298 Resource Parkway Dekalb, IL 60115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview and record review the facility failed to provide the residents with food that is palatable in flavor. This applies to all residents in the facility. Findings Include:The CMS (Centers for Medicare and Medicaid) 671 form dated 9/2/2025 shows there are 68 residents in the facility. The menu for lunch on 9/2/2025 shows a pork and rice casserole was to be served. At 11:40 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 (Resident R8, Resident R13, Resident R50, Resident 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, Resident 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.

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bethany Rehab & Hcc

3298 Resource Parkway Dekalb, IL 60115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

Resident R11's sacral wound. V11 again picked the scissors up from Resident R11's bed and began shaping a large piece of black foam, placed this foam with the wound bed then proceeded to cut the clear, silicone adhesive drape into strips. After V11 had cut several strips of drape, she placed the scissors on the bed then proceeded to apply the strips of drape onto the skin surrounding Resident R11's wound then covered the top of the wound and large piece of black foam with a larger piece of drape. At no time did this surveyor observe V11 place the scissors on a clean surface or sanitize the scissors after removing from Resident R11's bed and/or between use of cutting open packages and the black 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 Resident 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.”

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet