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Complaint Investigation

Belhaven Nursing & Rehab Center

August 27, 2025 · Chicago, IL · 11401 South Oakley Avenue
Citations 2
CMS Rating 1/5
Beds 221
Provider ID 145549
Healthcare Facility
Belhaven Nursing & Rehab Center
Chicago, IL  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Belhaven Nursing & Rehab Center in CHICAGO, IL — inspection on August 27, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0760
Pharmacy Service Deficiencies

Guidelines, (Undated), documents in part, .

Medications are administrated as prescribed, in

orders of the attending physician.routine medications are administered according to the established

administering a medication, in the space provided under the date, and on the line for that specific medication dose administration.11. If a dose of regularly scheduled medication is withheld, refused, . the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided.If two consecutive doses of a medication are withheld or refused, the physician is notified.8/25/2025 Facility's document titled, Job Description Administrator (Revised date August 21,2023), documents, in part, .Monitor each departments activities, communicate policies, .monitor operations of all departments.8/25/2025 Facility's document titled, Job Description Licensed Practical Nurse (Undated), documents, in part,.B.

Role Responsibilities - Charting and Documentation.5.

Charts nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care.C.

Role Responsibilities-Drug Administration: 1.

Prepares and administers medications as ordered by the physician.5.

Orders prescribed medications, supplies, and equipment as necessary.8/25/2025 Facility's document titled, Job Description Registered Nurse, (Undated), documents, in part,.B.

Role Responsibilities - Charting and Documentation.5.

Charts nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care.C.

Role Responsibilities-Drug Administration: 1.

Prepares and administers medications as ordered by the physician.5.

Orders prescribed medications, supplies, and equipment as necessary.8/25/2025 Facility's document titled, Job Description Director of Nursing, (Undated), documents, in part, .Under the supervision of the Administrator, the Director of Nursing has the authority, responsibility, and accountability for the functions, activities, and training of the nursing services staff.The DON is responsible for the overall management of resident care 24 hours a day, seven(7) days per week.B.

Role Responsibilities - Administrative Duties.2.

Supervise, evaluates, counsels, and disciplines inter-departmental personnel.

145549 08/27/2025

Belhaven Nursing & Rehab Center 11401 South Oakley Avenue Chicago, IL 60643

kitchen staff to address the matter of food preparation being delayed and sent out late to the

a planned schedule that allows no more than 14 hours between dinner the previous evening and

areas.A.

Posting in kitchen should include service times for all service areas. B.

Postings in service areas should include time for that service area only.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CHICAGO, IL, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Belhaven Nursing & Rehab Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.