Inspection·March 17, 2025

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident was provided ADL (Activity of Daily Living) care prior to transfer to hospital for (R1) 1 of 3 residents reviewed for ADL care in the sample of 3. Residents Affected - Few The findings include: R1's face sheet printed on 3/17/25 show R1 had diagnoses that include COVID 19 positive, Dementia and Anxiety. R1's facility assessment dated [DATE] under functional ability show R1 is frequently incontinent of bowel and bladder and needs assistance with transfers and toileting. R1's progress note dated 3/12/25 timed at 18:45 (6:45 PM) show R1's oxygen saturation was low (at 85%). R1 was being sent to the hospital for evaluation via 911. R1's hospital record dated 3/12/25 documents- upon arrival to Emergency Department (ED), pt/patient was noted to have soaked brief and her pants/linens underneath her were soaked all the way down to her ankles with odorous urine. On 3/17/25 at 10:38 AM, V4 (License Practical Nurse-LPN) stated on 3/12/25, she was R1's PM shift Nurse. V4 stated she received report that R1 was having a change in condition. R1 was placed on oxygen due to her Oxygen saturation (O2 sats) were low. V4 (LPN) said R1 was being closely monitored. R1 was placed in her wheelchair by the Nurses Station. R1's O2 sats remained low, and it was in the 80's. V4 said she notified R1's physician and R1 was sent to the hospital via 911. V4 stated I was focused on (R1's) condition, she was weak, I did not want anything bad to happen to her, I wanted to send her out to the hospital right away. I assumed the CNAs (Certified Nursing Assistant) should know their job of making sure R1 was clean and dry prior to transport to ER. On 3/17/25 at 10:50 AM, V5 (Certified Nursing Assistant-CNA) said on 3/12/25 she was working PM shift. V5 (CNA) stated she came in at 2PM. V5 stated she was told that R1 was just checked and changed. R1 was by the Nurses Station. At around 4:30 PM, she wheeled R1 to the dining room. V5 stated she did not change R1 at that time. V5 stated she was told that R1 was taken from the dining room and that R1 will be fed in the nurse's station. After dinner, V5 stated she saw R1 sitting in her wheelchair in the Nurses Station. V5 stated R1 was visibly wet on her frontal area but she thought R1 spilled water on herself since she saw an empty cup by the counter. Prior to R1 going to the hospital, R1 was lifted from her chair, and her bottom was wet. V5 stated R1 needed to be brought to her room to be changed. V5 stated she was told the (paramedics) were already on their way to get R1 to take her to the hospital. V5 confirmed she did not change R1's incontinent pad and she did not provide (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145958 Printed: 05/15/2026 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 145958 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2025 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)