Belhaven Nursing & Rehab: Mealtime Neglect Violations - IL
Inspectors observed this on August 14, 2025, during the lunch meal. The sequence lasted more than ten minutes.
At 1:02 p.m., a server set a fresh plate of pureed food in front of the resident, identified in inspection records as R10, and walked away. R10 began eating slowly with his right hand, his head tilted to the left. By 1:06, food particles had collected in his chin beard. He kept eating. By 1:10, he was filling his mouth with pureed food despite still having food in it from the previous bite. No staff were assisting him.
At 1:11, he grabbed more food with his hand.
A licensed practical nurse placed a chair next to R10 at 1:11 and then walked away toward the nurses' station. She returned one minute later with a paper towel. "Let me help you," she told him, and began feeding him, cueing him to slow down.
She told inspectors she stepped in because R10 looked like he was struggling and she saw him eating with his hand. "I asked the CNA to get me a towel so I can clean him off or something and continue to feed him," she said. She added that it is important to help residents who have food stains around their mouths "for dignity reasons."
R10's medical records describe a man who had suffered a stroke that left him with hemiplegia on his left side, muscle wasting, lack of coordination, and dysphagia — difficulty swallowing — as a direct result of that stroke. He had vascular dementia. His care plan noted he was at risk for weight loss, pain, fatigue, and complications from protein-calorie malnutrition. It called for staff to assist with activities of daily living and allow time to maintain his independence. His restorative nursing evaluation, dated July 16, 2025, documented that he needed feeding assistance with meals and was on a mechanical soft diet because of his dysphagia.
His care plan stated he "usually requires extensive assistance and 1 person support for eating."
The Director of Nursing told inspectors that afternoon that a resident who needs assistance should not sit with food particles on their face. "You would want to wipe their face," she said.
A second resident, R9, had a physician's order on file requiring one-to-one feeding assistance at every meal. R9's records document moderate cognitive impairment with poor decision-making, a diagnosis that includes epilepsy, dystonia, schizophrenia, and COPD, and a formal determination that R9 requires substantial to maximal assistance with eating — meaning staff are expected to do more than half the physical effort involved in getting food into the resident's mouth. The inspection report does not describe what inspectors observed with R9 during this visit, but the care requirements on file made clear that unassisted eating was not a safe option.
The facility's own written policy on daily care states that residents are to be assisted with eating by a certified nursing assistant or nurse, that staff should do all required documentation, and that the goal is to promote hygiene, provide comfort, and create a homelike environment.
What inspectors documented at the lunch table on August 14 was something different: a man with a paralyzed left arm and a swallowing disorder, picking up pureed food with his fingers and pushing it into a mouth that wasn't yet empty, while staff moved chairs and walked to nurses' stations, and nobody intervened for more than ten minutes.
The nurse who eventually helped him said she did it because he looked like he was struggling. His care plan had said he needed the help before he ever sat down.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Belhaven Nursing & Rehab Center from 2025-08-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 4, 2026 · Our methodology
Belhaven Nursing & Rehab Center in CHICAGO, IL was cited for neglect violations during a health inspection on August 15, 2025.
Inspectors observed this on August 14, 2025, during the lunch meal.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.