Belhaven Nursing & Rehab Center

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the plate and asked the server if she had more pureed. On 08/14/2025 at 1:02 PM V14 placed a new plate with pureed food in front of Resident R10 and walked away. Resident R10 began slowly eating with his right hand. Resident R10's head is titled to the left a bit. On 08/14/2025 at 1:06 PM eating more, slowly, chin beard filled with food particles.

No staff assisting Resident R10 noted. On 08/14/2025 at 1:10 PM, Resident R10 is still eating, filling mouth with pureed food.

Despite having more food still in his mouth.On 08/14/2025 1:11 PM, Resident R10 grabbed food with his hand. V5 (Licensed Practical Nurse) placed a chair next Resident R10 and walked away towards nurse's station. On 08/14/2025 at 1:12PM, V5 walked back to Resident R10, noted with paper towel in her hand and told Resident R10 let me help you. V5 fed him and cued him to take his time. On 08/14/2025 at 1:15 PM, V5 stated that she initiated to assist Resident R10 because V5 saw Resident R10 eat with his hand, and Resident R10 looked like he was struggling. V5 stated I asked the CNA to get me a towel so I can clean him off or something and continue to feed him. V5 stated that it is important to help the residents if they have food stains around their mouths for dignity reasons.On 08/14/2025 at 3:06 PM V2 (Director of Nursing) stated that a resident who needs assistance should not sit there with food particles on their face. V2 stated you would want to wipe their face. Resident R9's face sheet documents Resident R9 is a [AGE] year-old individual with diagnoses not limited to: chronic obstructive pulmonary disease, unspecified, schizophrenia, unspecified, dystonia, unspecified, anxiety disorder, unspecified, essential (primary) hypertension, epilepsy, unspecified.Resident R9's MDS/Minimum Data Set, dated [DATE REDACTED] documents that Resident R9's cognitive skills for daily decision making are moderately impaired- decisions poor; cues/supervision required. Resident R9's MDS/Minimum Data Set section GG dated 08/05/2025 documents in part Resident R9 requires substantial/maximal assistance (helper does more than half the effort) for eating. Resident R9's active physician order dated 08/09/2024 documents in part 1:1 feeder. Resident R10's face sheet documents Resident R10 is a [AGE] year-old individual with diagnoses not limited to: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, muscle wasting and atrophy, unspecified lack of coordination, need for assistance with personal care, vascular dementia, dysphagia following cerebral infarction.Resident R10's MDS/Minimum Data Set section GG dated 07/16/2025 documents in part Resident R10 requires partial/moderate assistance (helper does less than half the effort) for eating. Resident R10's care plan documents in part Resident R10 is at risk for weight loss, pain, fatigue and other complications r/t (related to) protein-calorie malnutrition. Assist with ADL's (assistance of daily living) as needed and allow time to maintain independence.Resident R10's care plan documents in part Resident R10 has a self-care deficit and requires assistance with ADLs to maintain highest possible level of functioning as evidenced by the following limitations and potential contributing factors: impaired cognitive status with diagnosis of dementia, weakness. Interventions document in part Resident R10 usually requires extensive assistance and 1 person support for eating.Resident R10's restorative nursing evaluation dated 7/16/2025 11:10 am documents in part Resident R10 has an active diagnosis of hemiplegia. pmHX (past medical history): CVA (Cerebrovascular Accident) w/left sided hemiplegia, requires extensive assist with most ADLs and transfers, able to stand pivot during transfers. Needs feeding assist w/meals on mechanical soft diet DX (diagnosis): Dysphagia.Facility document not dated titled activities of daily living documents in part residents are given routine daily care by a CNA (certified nursing assistant) or a nurse to promote hygiene, provide comfort and provide a homelike environment. Assistant the resident in personal care such as bathing, showering, dressing, eating, hair care, oral care, nail care, appropriate skin care (as indicated and as per care plan) as well as encouraging participating in physical, social, and reactional activities. Do all required ADL (activities of daily living) documentation as required per policy and regulations.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Belhaven Nursing & Rehab Center

11401 South Oakley Avenue Chicago, IL 60643

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)

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review the facility failed to a.) ensure drinks consumed are in the appropriate form as ordered by the physician for one resident (Resident R10) b.) provide the appropriate nutrient content as ordered by the physician order for two (Resident R8, Resident R9) out of ten residents reviewed for dietary services. This failure places the resident at risk for more than minimal harm.Findings include:On 08/13/2025 at 12:24 PM Resident R8 stated I'm supposed to get two cheeseburgers as he is showing his diet slip to

a staff member. V12 (Dietary Aide) nodded her head no, they didn't make another one. then she looked at surveyor and said give me a minute.On 08/13/2025 at 12:39 PM, Resident R8 standing at the nurse's station, stated that he did not receive another cheeseburger. Resident R8 stated sometimes they do give me my double portions but not today or yesterday. Resident R8's MDS/Minimum Data Set, dated [DATE REDACTED] documents that Resident R8 has a BIMS/Brief

Interview for Mental Status score of 15/15, indicating that Resident R8 has intact cognition. Resident R8's active physician order dated 05/23/2025 documents in part double portions diet, Regular texture, Thin Liquids consistency. for double portion. On 08/14/2025 12:44 PM, Resident R9's lunch tray placed in front of Resident R9, no double portion protein noted on his plate (one scoop of chopped chicken, rice, carrots), and on Resident R9's tray also chocolate pudding in

a small bowel, and a cup of juice noted.Resident R9's active physician order/dietary order dated 05/22/2025 documents in part general diet mechanical soft texture, thin liquids consistency, double portion protein for nutrition. On 08/14/2025 at 12:41 PM Resident R10's head down, leaning forward. Staff member placed a lunch tray

on the table in front of Resident R10. No magic cup noted on Resident R10's meal tray.On 08/14/2025 at 12:48 PM, Resident R10 eating slowly trying to get some of the pureed food. Resident R10 grabbed a cup off his lunch tray and drank the thin liquid juice. No acute distress noted. On 08/14/2025 at 12:53 PM V14 (Certified Nursing Assistant) stated I am not the one who gave him his tray as V14 grabbed Resident R10's liquid thin juice and provided Resident R10 with thickened liquid apple juice. V14 stated not sure if it is fruit punch juice but it is thin liquid. Resident R10's active physician diet order dated 05/22/2025 documents in part NAS = no salt packet on tray diet, pureed texture, nectar consistency. magic cup with lunch and dinner for diet.On 08/14/2025 at 3:06 PM V2 (Director of Nursing) V2 stated that it is important to follow diet orders because number one goal is always safety.

Someone might be on a cardiac or renal, or pureed, mechanical soft diet based on their diagnosis and assessments. V2 stated that if there is an order for a resident to have double portion meal, then they should receive double portion. V2 stated it means what they can tolerate. V2 stated that if a resident who has an order for thickened liquids drinks thin liquids, it can place the resident at risk for aspiration. V2 stated that some complication of aspirating is aspiration pneumonia, choking. V2 stated that if a resident is given thin liquids instead of thickened liquids that is an example of not following diet orders. V2 stated that residents are honored their right to be treated with dignity and respect during mealtimes you would want to make sure they receive their appropriate meal trays.

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