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Bethesda Rehab & Senior Care

Bethesda Rehab & Senior Care has 80 certified beds that participates in Medicare and Medicaid. The ownership of the facility is a non-profit corporation. Bethesda Rehab & Senior Care has an overall rating of below average. It is not in a continuing care retirement community. Bethesda Rehab & Senior Care is located on Chicago’s west side in the Montclare neighborhood.

The Illinois Department of Health and Human Services regularly inspects Illinois nursing homes approximately every 18 months. One such inspection and full report was done on the Bethesda Rehab & Senior Care on June 16, 2016. In that report, it was shown as a summary statement that (1) hire only people with no legal history of abusing, neglecting or mistreating residents or (2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.

Based on interview and record review, Bethesda Rehab & Senior Care failed to immediately report an allegation of abuse to the abuse coordinator for one resident. An initial abuse report sent by way of fax by the Director of Nursing to the state regulatory agency was done on August 29, 2015. The report indicated that the certified nurse assistant (CNA) reported that a family member appeared to be forcefully inserting dentures into a resident’s mouth and her wrist held during dinner. There was no mouth injury to the resident but there was possible bruising that developed on her left wrist. The Director of Nursing was informed that a family member of the resident had been forceful towards the resident the night before.

In another issue at Bethesda Rehab & Senior Care, based on observation, interview and record review, the facility failed to ensure and maintain sanitary residents’ personal care items and care equipment through improper storage and labeling. This deficiency had the potential to affect two of eight residents reviewed for housekeeping and maintenance services in the sample of fourteen. In this review, it was found that two uncontained and unlabeled basins were stored on the floor under the sink. An unlabeled water pitcher was placed at the sink countertop.

In another deficiency, it was found that Bethesda Rehab & Senior Care had failed to give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers) and helped restore eating skills, if possible.

The overall rating for the staffing at Bethesda Rehab & Senior Care was above average. In fact, the registered nurse staffing rating was much above average. The total number of licensed staff hours per resident per day at Bethesda Rehab & Senior Care was 1 hour and 23 minutes. This compared to the Illinois average of 1 hour and 33 minutes and the national average of 1 hour and 42 minutes. The registered nurse hours per resident per day was 53 minutes compared to 56 minutes and 51 minutes for the Illinois and national averages, respectively. The CNA hours per resident per day were shown to be 2 hours and 39 minutes at Bethesda Rehab & Senior Care, whereas the Illinois average is 2 hours and 15 minutes. The physical therapy staff hours per resident per day at Bethesda Rehab & Senior Care was less than 1 minutes. This was substantially lower than both the Illinois and U.S. averages in this category. Both Illinois and the national averages are 6 minutes for physical therapy staff hours per resident per day.

Bethesda Rehab & Senior Care’s short-stay residents made improvements in function at the rate of 73.8%. That percentage was significantly higher than the Illinois average of 60.1% and the national average of 63.3% in this category. 22.5% of Bethesda Rehab & Senior Care’s short-stay residents were re-hospitalized after a nursing home admission. This compared identical to the Illinois average and close to the national average. 60.2% of Bethesda Rehab & Senior Care’s short-stay residents were successfully discharged to the community. In this category Bethesda Rehab & Senior Care performed better than both Illinois and the U.S. on average.

5.4% of Bethesda Rehab & Senior Care’s long-stay high-risk residents suffered from pressure ulcers. This percentage was lower than the Illinois average of 6.3% and the national average of 5.8%. There was no report of any Bethesda Rehab & Senior Care’s long-stay residents who were physically restrained. 99.6% of Bethesda Rehab & Senior Care’s long-stay residents were assessed and given the appropriate seasonal influenza vaccine. This near perfect score was better than both the Illinoi and national averages in this category.

Bethesda Rehab & Senior Care was not the recipient of any federal fines in the last 3 years. However, this does not mean that there may have been an Illinois fine imposed under state law.

1 Vital Statistics
Number of Beds: 96 certified bedsinformation

Beds in the nursing home that have been approved by the federal government to participate in Medicare or Medicaid.

Accepts: Medicare and Medicaidinformation

Shows if the nursing home participates in the Medicare, Medicaid, or both.

2 Key Ratings
Star Rating Summary
Overall Rating information

Medicare assigns the overall star rating based on a nursing homes's performance on 3 separate measures: Health inspections, staffing, and quality measures. Each of these domains have their own star ratings, with more stars meaning better quality of care

Four Stars Above Average
Health Inspection information

Medicare assigns the star rating based on a nursing home’s weighted score from recent health inspections. More stars means fewer health risks

Four Stars Above Average
Staffing information

Medicare assigns the star rating based on the nursing home’s staffing hours for Registered Nurses (RNs), Licensed Practice Nurses (LPNs), Licensed Vocational Nurses (LVNs), and Nurse aides. More stars means a better level of staffing per nursing home resident

Four Stars Above Average
RN Staffing Five Stars Much Above Average
Quality Measures information

Medicare assigns the star rating based on data from a select set of clinical data measures. More stars means better quality of care

Four Stars Above Average
3 Key Short Stay Statistics
Description Bethesda Rehab & Senior Care Illinois
Average
Percent of short-stay residents who self-report moderate to severe pain
Lower percentages are better.
7.5% 10.2%
Percentage of SNF residents with pressure ulcers that are new or worsened
Lower percentages are better.
2.6% Not Available
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
Higher percentages are better.
64.1% 72.8%
Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine
Higher percentages are better.
63.7% 74.7%
Percentage of short-stay residents who got antipsychotic medication for the first time
Lower percentages are better.
0.5% 2.1%
4 Key Long Stay Statistics
Description Bethesda Rehab & Senior Care Illinois
Average
Percent of long-stay residents experiencing one or more falls with major injury
Lower percentages are better.
3.2% 3.3%
Percent of long-stay residents with a urinary tract infection
Lower percentages are better.
1.4% 3.1%
Percent of long-stay residents who self-report moderate to severe pain
Lower percentages are better.
2.0% 4.9%
Percent of long-stay high-risk residents with pressure ulcers
Lower percentages are better.
21.2% 7.6%
Percent of long-stay low-risk residents who lose control of their bowels or bladder
Lower percentages are better.
62.5% 46.1%
Percent of long-stay residents who have or had a catheter inserted and left in their bladder
Lower percentages are better.
1.4% 2.4%
Percent of long-stay residents who were physically restrained
Lower percentages are better.
0.0% 0.3%
Percentage of long-stay residents whose ability to move independently worsened
Lower percentages are better.
30.9% 16.5%
Percent of long-stay residents whose need for help with daily activities has increased
Lower percentages are better.
28.5% 13.8%
Percent of long-stay residents who lose too much weight
Lower percentages are better.
14.1% 6.3%
Percent of long-stay residents who have depressive symptoms
Lower percentages are better.
0.0% 19.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication
Lower percentages are better.
5.6% 20.2%
Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine
Higher percentages are better.
96.2% 92.9%
Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine
Higher percentages are better.
84.2% 89.7%
Percent of long-stay residents who received an antipsychotic medication
Lower percentages are better.
21.6% 18.8%
5 Inspection Summary

Date of standard health inspection: 08/23/2018
Total number of health deficiencies: 7
Average number of health deficiencies in Illinois: 10.6

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