Health inspection·February 24, 2026

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 observation, interview, and record review, the facility failed to ensure Activities of Daily Living (ADL) assistance was provided to residents that required assistance for three of ten residents (R9, R1, R2) reviewed for ADLs in the sample of ten.The findings include:1.R9's admission Record shows she was admitted to the facility on [DATE], with diagnoses including diabetes mellitus, weakness, unsteadiness on feet, dysphagia, anxiety disorder, high blood pressure, heart disease, gastro esophageal reflux disease, and osteoarthritis. R9's Care Plan shows R9 has an ADL self-care performance deficit. R9 requires the assistance of one staff member with bathing, personal hygiene, and oral care. R9 has refused to be shaven, if R9 resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again. If possible, negotiate a time for ADLs so that the resident participates in the decision-making process. Return at the agreed upon time.On February 23, 2026, at 1:17 PM, R9 was sitting in her wheelchair in her room. R9 had long gray hairs on her chin. R9 said, I need a shave and rubbed the hair on her chin. R9 said she likes her chin to be shaved.2. R1's admission Record shows she was admitted to the facility on [DATE], with diagnoses including epilepsy, weakness, morbid obesity, contracture of left hand, need for assistance with personal care, generalized anxiety disorder, major depressive disorder, and arthritis. R1 Care Plan shows R1 has an ADL self-care performance deficit. R1 has a contracture to her left hand. R1 requires assistance with one staff member for bathing, personal hygiene, and oral care.On February 23, 2026, at 10:49 AM, R1 was laying on her back in her bed. R1 had small hair on her chin/neck area. R1 said she has asked to be shaven. R1 said she would like facility staff to shave her chin.3. R2's admission Record shows she was admitted to the facility on [DATE], with diagnoses including multiple sclerosis, cognitive communication deficit, dementia, disorder of central nervous system, urinary tract infection, deep vein thrombosis, dysphagia, and major depressive disorder. R2's Care Plan shows R2 has an ADL self-care performance. R2 requires one staff member to help with bathing, personal hygiene, and oral care.On February 23, 2026, at 9:26 AM, R2 was sitting in her wheelchair in her room. There was a splint to R2's right hand. R2's nails on her right hand were long especially her pinky nail. R2's ring finger was also long with a substance under her nails. R2 said she would like the nails on her right hand to be shorter. On February 23, 2026, at 3:01 PM, V5 Regional Nurse Consultant said certified nursing assistants should shave residents and cut their nails, unless the resident is a diabetic. V5 said if a resident is a diabetic, then the nurse does it. The facility's Activities of Daily Living policy approved September 24, 2025, shows, This facility provides each resident with care, treatment, and services according to the resident's individualized care plan. Residents Affected - Few Page 1 of 5 145958 145958 02/24/2026 Bethany Rehab & Hcc 3298 Resource Parkway Dekalb, IL 60115

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide medications as ordered for five of ten residents (R1, R2, R4, R5, R9) reviewed for medications in the sample of ten.The findings include:1.R1 was admitted to the facility on [DATE], with diagnoses including epilepsy, weakness, morbid obesity, contracture of left hand, need for assistance with personal care, generalized anxiety disorder, major depressive disorder, and arthritis. R1's Medication Administration Record (MAR) dated February 1, 2026-February 28, 2026 shows orders for buspirone tablet 15 mg (milligrams) two times a day related to anxiety disorder scheduled at 9:00 AM and 5:00 PM, carbamazepine extended release tablet 100 mg give three tablets two times a day for antiseizure at 9:00 AM and 5:00 PM and two tablets by mouth at 12:00 PM, and losartan potassium 50 mg by mouth daily for high blood pressure hold if top number in blood pressure < 100. On February 23, 2026, at 11:16 AM, V4 Registered Nurse (RN) took R1's blood pressure. R1's blood pressure was 107/60. R1 complained of nausea, so V4 gave R1 an antinausea medication and said she will come back to administer the above morning medications. At 1:14 PM, V4 was asked if she had given R1 her morning scheduled medications and V4 said, No, not yet.R1's MAR shows that V4 held R1's losartan potassium although R1's blood pressure was not below the doctor's parameters to hold the medication. 2.R2's admission Record shows she was admitted to the facility on [DATE], with diagnoses including multiple sclerosis, cognitive communication deficit, dementia, disorder of central nervous system, urinary tract infection, deep vein thrombosis, dysphagia, and major depressive disorder. R2's MAR dated February 1, 2026-February 28, 2026, shows an order for propranolol 10 mg give one tablet by mouth three times a day related to high blood pressure scheduled at 9:00 AM, 1:00 PM, and 9:00 PM, and an order for primidone 50 mg give two tablets by mouth five times a day related to disorder of central nervous system scheduled at 6:00 AM, 9:00 AM, 12:00 PM, 4:00 PM, and 9:00 PM. On February 23, 2026, at 10:30 AM, V3 RN administered R2's 9:00 AM scheduled morning medications.3. R4's admission Record shows she was admitted to the facility on [DATE], with diagnoses including diabetes mellitus with unspecified diabetic retinopathy with macular edema, history of falling, pain, weakness, age related nuclear cataract, macular degeneration, dry eye syndrome, and major depressive disorder. R4's MAR dated February 1, 2026-February 28, 2026, shows an order for Preservision oral tablet (multiple vitamins with minerals) give one tablet by mouth two times a day related to type 2 diabetes with diabetic retinopathy with macular edema scheduled at 9:00 AM and 5:00 PM.On February 23, 2026, at 10:08 AM, V3 RN said she did not have R4's ordered eye vitamin.4. R5's admission Record shows he was admitted to the facility on [DATE], with diagnoses including polycythemia vera (rare chronic blood cancer) osteoarthritis, dysphagia, high blood pressure, weakness, cognitive communication deficit, atrial fibrillation, hypothyroidism, heart failure, dementia, major depressive disorder, and history of falling.R5's MAR dated February 1, 2026-February 28, 2026, shows orders for cyanocobalamin (a vitamin) 1000 mcg (micrograms) daily at 9:00 AM, hydroxyurea (chemotherapy medication) 500 mg give two capsules by mouth daily at 9:00 AM related to polycythemia vera, metoprolol 25 mg give 1/2 tablet at 9:00 AM and 9:00 PM every morning and bedtime related to high blood pressure, Mucinex extended release tablet 600 mg at 9:00 AM and 9:00 PM every morning and at bedtime, diltiazem 30 mg give one tablet by mouth three times a day at 9:00 AM, 1:00 PM, and 8:00 PM related to high blood pressure and heart failure, and Systane eye drops in both eyes three times a day at 9:00 AM, 1:00 PM, and 9:00 PM for dry eyes. On February 23, 2026 at 10:36 AM, V4 RN administered the above medications to R5 (over one hour late). V4 administered cyanocobalamin 50 mcg instead of the ordered 1000 mcg, gave one tablet of hydroxyurea instead of the ordered two tablets, 145958 Page 2 of 5 145958 02/24/2026 Bethany Rehab & Hcc 3298 Resource Parkway Dekalb, IL 60115

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some held R5's metoprolol although there were no parameters to do so, administered Mucinex 400 mg instead of the ordered 600 mg, administered diltiazem over one hour late, and said she did not have the ordered eye drops for R5. 5. R9's admission Record shows she was admitted to the facility on [DATE], with diagnoses including diabetes mellitus, weakness, unsteadiness on feet, dysphagia, anxiety disorder, high blood pressure, heart disease, gastro esophageal reflux disease, and osteoarthritis. R9's MAR dated February 1, 2026-February 28, 2026 shows orders for docusate sodium 100 mg two times a day for constipation at 9:00 AM and 5:00 PM, famotidine 20 mg give one tablet by mouth two times a day for acid indigestion at 9:00 AM and 5:00 PM, and metoprolol succinate tablet 25 mg give one tablet by mouth two times a day at 9:00 AM and 5:00 PM. On February 23, 2026, V4 administered R9's 9:00 AM scheduled medications at 11:00 AM.On February 23, 2026, at 3:01 PM, V5 Regional Nurse Consultant said medications should be administered within one hour before or one hour after the scheduled time. The nurse should let the doctor know if the medications are late to see if there's any new orders. Medications should only be held if there are doctor ordered parameters. If there are no parameters, then the doctor should be called. V5 said she believe artificial tears to be a facility stock medication. V5 said she also believed that eye vitamins are a facility stock medication, but if they are not, then the staff should order the medication through the pharmacy. The facility Medication Administration Schedule policy approved on November 2025 shows, Medication shall be administered according to established schedules. 145958 Page 3 of 5 145958 02/24/2026 Bethany Rehab & Hcc 3298 Resource Parkway Dekalb, IL 60115

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility to ensure medications were administered and administered at the prescribed time for two of two residents (R5, R4) observed during the medication pass. There were 25 opportunities with 7 errors, resulting in a 28% error rate.The findings include:1.R5's admission Record shows he was admitted to the facility on [DATE], with diagnoses including polycythemia vera (rare chronic blood cancer) osteoarthritis, dysphagia, high blood pressure, weakness, cognitive communication deficit, atrial fibrillation, hypothyroidism, heart failure, dementia, major depressive disorder, and history of falling.R5's MAR dated February 1, 2026-February 28, 2026, shows orders for cyanocobalamin (a vitamin) 1000 mcg (micrograms) daily at 9:00 AM, hydroxyurea (chemotherapy medication) 500 mg (milligrams) give two capsules by mouth daily at 9:00 AM related to polycythemia vera, metoprolol 25 mg give 1/2 tablet at 9:00 AM and 9:00 PM every morning and bedtime related to high blood pressure, Mucinex extended release tablet 600 mg at 9:00 AM and 9:00 PM every morning and at bedtime, diltiazem 30 mg give one tablet by mouth three times a day at 9:00 AM, 1:00 PM, and 8:00 PM related to high blood pressure and heart failure, and Systane eye drops in both eyes three times a day at 9:00 AM, 1:00 PM, and 9:00 PM for dry eyes. On February 23, 2026, at 10:36 AM, V4 RN administered the above medications to R5 (over one hour late). V4 administered cyanocobalamin 50 mcg instead of the ordered 1000 mcg, gave one tablet of hydroxyurea instead of the ordered two tablets, held R5's metoprolol although there were no parameters to do so, administered Mucinex 400 mg instead of the ordered 600 mg, administered diltiazem over one hour late, and said she did not have the ordered eye drops for R5. 2. R4's admission Record shows she was admitted to the facility on [DATE], with diagnoses including diabetes mellitus with unspecified diabetic retinopathy with macular edema, history of falling, pain, weakness, age related nuclear cataract, macular degeneration, dry eye syndrome, and major depressive disorder. R4's MAR dated February 1, 2026-February 28, 2026, shows an order for Preservision oral tablet (multiple vitamins with minerals) give one tablet by mouth two times a day related to type 2 diabetes with diabetic retinopathy with macular edema scheduled at 9:00 AM and 5:00 PM.On February 23, 2026, at 10:08 AM, V3 RN said she did not have R4's ordered eye vitamins.On February 23, 2026, at 3:01 PM, V5 Regional Nurse Consultant said medications should be administered within one hour before or one hour after the scheduled time. The nurse should let the doctor know if the medications are late to see if there's any new orders. Medications should only be held if there are doctor ordered parameters. If there are no parameters, then the doctor should be called. V5 said she believe artificial tears to be a facility stock medication. V5 said she also believed that eye vitamins are a facility stock medication, but if they are not, then the staff should order the medication through the pharmacy. The facility Medication Administration Schedule policy approved on November 2025 shows, Medication shall be administered according to established schedules. Residents Affected - Few 145958 Page 4 of 5 145958 02/24/2026 Bethany Rehab & Hcc 3298 Resource Parkway Dekalb, IL 60115

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure significant medication errors did not occur for two of ten residents (R1, R5) reviewed for medications in the sample of ten.The findings include:1.R1 was admitted to the facility on [DATE], with diagnoses including epilepsy, weakness, morbid obesity, contracture of left hand, need for assistance with personal care, generalized anxiety disorder, major depressive disorder, and arthritis. R1's Medication Administration Record (MAR) dated February 1, 2026-February 28, 2026, shows orders for carbamazepine extended-release tablet 100 mg (milligrams) give three tablets two times a day for antiseizure at 9:00 AM and 5:00 PM and two tablets by mouth at 12:00 PM, and losartan potassium 50 mg by mouth daily for high blood pressure hold if top number in blood pressure < 100. On February 23, 2026, at 11:16 AM, V4 Registered Nurse (RN) took R1's blood pressure. R1's blood pressure was 107/60. R1 complained of nausea, so V4 gave R1 an antinausea medication and said she will come back to administer the above morning medications. At 1:14 PM, V4 was asked if she had given R1 her morning scheduled medications and V4 said, No, not yet.R1's MAR shows that V4 held R1's losartan potassium although R1's blood pressure was not below the doctor's parameters to hold the medication. 2.R5's admission Record shows he was admitted to the facility on [DATE], with diagnoses including polycythemia vera (rare chronic blood cancer), osteoarthritis, dysphagia, high blood pressure, weakness, cognitive communication deficit, atrial fibrillation, hypothyroidism, heart failure, dementia, major depressive disorder, and history of falling.R5's MAR dated February 1, 2026-February 28, 2026, shows orders for hydroxyurea (chemotherapy medication) 500 mg give two capsules by mouth daily at 9:00 AM related to polycythemia vera, metoprolol 25 mg give 1/2 tablet at 9:00 AM and 9:00 PM every morning and bedtime related to high blood pressure, and diltiazem 30 mg give one tablet by mouth three times a day at 9:00 AM, 1:00 PM, and 8:00 PM related to high blood pressure and heart failure.On February 23, 2026, at 10:36 AM, V4 RN administered the above medications to R5 (over one hour late). V4 administered one tablet of hydroxyurea instead of the ordered two tablets, held R5's metoprolol although there were no parameters to do so, and administered diltiazem over one hour late. On February 23, 2026, at 3:01 PM, V5 Regional Nurse Consultant said medications should be administered within one hour before or one hour after the scheduled time. The nurse should let the doctor know if the medications are late to see if there's any new orders. Medications should only be held if there are doctor ordered parameters. If there are no parameters, then the doctor should be called. Pain medications, blood pressure medications, and seizure medications are all significant medications.The facility Medication Administration Schedule policy approved on November 2025 shows, Medication shall be administered according to established schedules.The facility does not have a policy in regard to significant medications. Residents Affected - Few 145958 Page 5 of 5