Belhaven Nursing & Rehab Center

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

medication, Resident R1 could experience potential seizure. Progress notes documents in part, that Resident R1 has past medical medication history includes Levetiracetam for seizures, phenobarbital and pregabalin for seizures.

Progress notes also documents in part, that Resident R1's treatment plan is to continue all seizures medications and that Resident R1 was advised to be consistent with medications adherence ,because it is a very important prevention of seizures. In the patient summary of the progress notes the seizure management states in part, that the key recommendation is strict adherence to all Resident R1's seizure medications, because it is necessary to prevent seizures recurrence.8/25/2025 Facility's policy titled Resident Rights, (Undated), documents in part, .At a minimum, Federal law specifies that nursing homes must protect and promote the following rights of each resident.Get proper Medical Care. 8/25/2025 Facility's policy titled, 2.6: Ordering medications (electronic), (December 2018), documents, in part,.refill orders are initiated within the electronic medical record system as follows: Reorder medication three days in advance of need to assure an adequate supply is on hand.8/25/2025 Facility's policy titled, 5.1: Drug Administration-General Guidelines, (Undated), documents

in part, . Medications are administrated as prescribed, in accordance with good nursing principles and practices.The licensed nurse is aware of an indication for the resident receiving medication.2. Medications are administered in accordance with written orders of the attending physician.routine medications are administered according to the established medication administration schedule for the facility.9. The resident's MAR is initialed by the person 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.

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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

08/27/2025

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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

available. Residents sitting at tables waiting for scheduled meal service to begin.On 08/26/2025 between 8am and 4pm V1(Administrator/ADMIN) and V2(Director of Nursing/DON) said they are aware of the situation with the kitchen sending out food trays late for scheduled meal services. They said concerns have been addressed with V9(Dietary Director) and stated the independent vendor is working to hire more kitchen staff to address the matter of food preparation being delayed and sent out late to the units.Surveyor reviewed Belhaven Meal Times for breakfast, lunch, and Dinner times.The Vendor Policy and Procedure Meal Service Schedule (no date) reads in part:Meals will be served according to a planned schedule that allows no more than 14 hours between dinner the previous evening and breakfast the next day. 1.

Procedure: Post meal service schedule in main kitchen and all service 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.

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