Belhaven Nursing & Rehab Center
Inspection History Overview
Detailed Inspection Reports
Notice: These are official CMS inspection narratives containing detailed regulatory findings. This information is not available in searchable format anywhere else online.
Fines and Penalties by Year
2025 2 penalties totaling $157,794
Fine
Fine
2022 15 penalties totaling $335,511
Fine
Fine
Fine
Fine
Fine
Fine
Fine
Fine
Payment Denial
Fine
Fine
Fine
Fine
Fine
Fine
2021 5 penalties totaling $484,738
Fine
Payment Denial
Fine
Fine
Payment Denial
2020 2 penalties totaling $15,000
Fine
Payment Denial
2017 1 penalties totaling $6,500
Fine
Health Violations by Year
2025 12 violations
Make sure that a working call system is available in each resident's bathroom and bathing area.
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Reasonably accommodate the needs and preferences of each resident.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Make sure that a working call system is available in each resident's bathroom and bathing area.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
2024 9 violations
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
2023 32 violations
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Reasonably accommodate the needs and preferences of each resident.
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Provide safe and appropriate respiratory care for a resident when needed.
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Ensure medication error rates are not 5 percent or greater.
Ensure that residents are free from significant medication errors.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Dispose of garbage and refuse properly.
Provide and implement an infection prevention and control program.
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
2022 40 violations
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
Ensure staff are vaccinated for COVID-19
Put firmly secured handrails on each side of hallways.
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Reasonably accommodate the needs and preferences of each resident.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide enough food/fluids to maintain a resident's health.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
2021 43 violations
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure services provided by the nursing facility meet professional standards of quality.
Plan the resident's discharge to meet the resident's goals and needs.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide safe, appropriate pain management for a resident who requires such services.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Respond appropriately to all alleged violations.
Allow residents to self-administer drugs if determined clinically appropriate.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
2020 6 violations
Provide and implement an infection prevention and control program.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
2019 17 violations
Provide care and assistance to perform activities of daily living for any resident who is unable.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide safe and appropriate respiratory care for a resident when needed.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure medication error rates are not 5 percent or greater.
Ensure that residents are free from significant medication errors.
Provide or obtain dental services for each resident.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
2018 19 violations
Reasonably accommodate the needs and preferences of each resident.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Keep residents' personal and medical records private and confidential.
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure medication error rates are not 5 percent or greater.
Ensure that residents are free from significant medication errors.
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Reasonably accommodate the needs and preferences of each resident.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
2017 21 violations
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Protect each resident from mistreatment, neglect and misappropriation of personal property.
Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Ensure residents maintain acceptable nutritional status.
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.
Provide food in a way that meets a resident's needs.
Store, cook, and serve food in a safe and clean way.
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
Have a program that investigates, controls and keeps infection from spreading.
Provide necessary care and services to maintain or improve the highest well being of each resident .
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Reasonably accommodate the needs and preferences of each resident.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
Belhaven Nursing & Rehab Center is a 1-star nursing home in CHICAGO, IL with 221 beds.
Most recent inspection: Data not available. No current violations on record.
📍 11401 SOUTH OAKLEY AVENUE, CHICAGO, IL
💵 Accepts Medicare and Medicaid