F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
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.
Based on observation, interviews, and record reviews the facility failed to maintain a safe, comfortable
home like environment,[A] failed to maintain room temperatures for four [R4, R5, R6, R7] of seven [R1, R2,
R3] residents reviewed for heating.
Findings include,
R1's clinical record indicates in part: R1 was admitted with the following medical diagnosis of paraplegia,
essential hypertension, opioid abuse, anxiety disorder, colostomy, abnormal posture, malaise, and
limitations of activities due to disability. R1's minimum data set [MDS] section [C] indicates R1 is cognitively
intact.
R1's care plan documents in part:
R1 presents with moderate to extreme anxiety related to: worry regarding medical symptoms and
conditions mood distress, anger, fear, and paranoia. This problem is manifested by verbal expressions of
distress and frequent complaints.
R1 displays manipulative behavior which is disruptive, insensitive, and disrespectful to staff and peers. This
behavior is related to anger and depression symptoms are manifest by frequent threats to call state survey
agency officials, ombudsman, attorneys, placing unjustified calls to police, threaten to report staff. R1's
symptoms are manifest by threatening or acting in a verbally or physically aggressive behavior manner.
On 5/3/25 at 10:10 AM observed R1 lying on an ambulance stretcher alert and oriented x3. R1 stated, I am
on my way to the emergency department to get my suprapubic catheter changed out. Sometimes at night
my room gets a little cool, but the nursing staff gives my extra blankets. Then there are times my room is
very hot, and I have asked V5 [Director of Maintenance] to turn the heat off in my room. But lately the
temperature in my room is good.
On 5/3/25 at 11:00 AM, R4 and R5 both said the heat in their room have not been working for two weeks.
R5 ask surveyor to turn the switch on the wall in an up position. R5 said the switch normally turns on the
heat. Surveyor pushed the switch upwards and a few seconds later R4, R5 and surveyor hear a popping
noise. Observed on the floor in front of the heating unit four colored wires, blue, red, black and white. R4
and R5 both said the wires was pulled out when staff was moving the beds around. R5 stated, I told serval
nurses about those wires hanging out.
On 5/3/24 at 11:22 AM, R6 and R7 said they were both cold and the heat would not turn on.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
145549
Printed: 05/15/2026
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
145549
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2025
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 0584
Surveyor and V5 [Maintenance Director] obtained temperature in the following rooms:
Level of Harm - Minimal harm
or potential for actual harm
R1's room temperature was 74 degrees Fahrenheit [F].
R2's room temperature was 72F.
Residents Affected - Some
R3's room temperature was 72F.
R4 and R5's room temperature was 70F. V5 stated, The heating unit is not working. The room temperatures
should be 72 to 82 degrees.
R6 and R7's room temperature was 65F.
On 5/3/25 at 11:45 AM, V5 [Maintenance Director] stated, I was not made aware that R4 and R5's room's
heating unit wires were laying outside the unit the heating unit is not working.
On 5/3/25 at 11:50AM, V5 stated, I was not made aware that R6 and R7's heating unit was not turning on.
The heating until motor needs to be replace, it is not coming on.
On 5/3/25 at 3:45 PM, V5 and surveyor went to R4, R5, R6, and R7's rooms the heating units were
working, and the room temperature was 72F. V5 stated, R4 and R5 heating unit was not working, I repaired
the wires, and the heating unit is now functioning properly. R6 and R7's motor in the heating unit was
working, I replaced the motor and now the heat is working.
On 5/3/25 at 2:40 PM, V1 [Administrator] stated, I have not received any concerns regarding the facility not
being warm. Last week the residents and staff complained the facility was too hot. V5 adjusted the heat
according to the weather and building temperatures. All residents should not go without heat in their rooms.
They all should be comfortable in a homelike environment. The residents room temperature should be
between 72 to 82 degrees.
Policy documented in part:
Resident Rights Ombudsman: Your facility must be safe, clean, comfortable, and homelike.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145549
If continuation sheet
Page 2 of 2
