F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to follow a physician order and monitor a resident's vital signs
for one (R1) out of four residents reviewed for quality of care in a total sample of four. This failure places
residents at risk to be provided with inappropriate care and services to meet the resident's physical, mental
and/or psychosocial needs. This failure places the resident at risk for more than minimal harm.
Residents Affected - Few
Findings include:
On 07/01/2025, at 12:56 PM, R1 stated that he saw V10 (Nurse Practitioner) about three weeks ago. R1
stated that he informed V10 that R1 has been having a lot of migraines which R1 stated that he never had
in his life. R1 stated, I'll be sitting there and physically feel that my blood pressure is high. R1 stated that
V10 ordered a medication which has been helping R1. R1 stated that the staff do not check his blood
pressure daily. R1 stated that the nurse did not check R1's blood pressure today nor any vital signs.
On 07/01/2025, at 11:49 AM, V6 (Registered Nurse) stated that R1 has an order for vital signs daily but no
option of recording them. V6 stated that she did monitor R1's vital signs today and wrote them on a piece of
paper which V6 threw out in the garbage and does not have the paper anymore. V6 stated that R1 does
have a diagnosis of hypertension on his face sheet. V6 stated that R1's last blood pressure recorded in
R1's blood pressure log is 138/77 mmHg (millimeters of mercury) dated 6/13/2025. V6 stated that
symptoms of high blood pressure a person may experience is dizziness, lightheaded, sweating, pain,
headache, flushing, chest discomfort, swelling to extremities. V6 stated that R1's vital signs should have
been documented in R1's electronic medical record.
R1's current face sheet documents R1 is a [AGE] year-old individual admitted to the facility on [DATE] and
has diagnoses not limited to: hypertension, chronic obstructive pulmonary disease, asthma.
R1's Minimum Data Set (MDS) Section C, dated 05/14/2025, documents R1 has a Brief Interview for
Mental Status (BIMS) of 15 out of 15, indicating R1 is cognitively intact.
R1's active physician order sheet/POS documents the following order: vital signs daily every day shift for
monitoring. This order is active since dated 01/25/2025.
R1's blood pressure log from April 2025 to June 2025. No blood pressure logged from April 2025 to May
2025. For June 2025 only one blood pressure reading (138/77 mmhHg) logged in the blood pressure log
dated 6/13/2025.
(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
07/03/2025
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
R1's nurse's note dated 6/24/2025, at 7:41 PM, documents in part R1's blood pressure read 143/78 mmHg.
No other blood pressure readings noted from April 2025 to June 2025.
R1's provider note dated 6/25/2025, 7:35 AM, documents in part cardiology medical necessity: f/u (follow
up) consult for cardiac med reconcile, titrating cardiac meds, lab follow up, following volume status,
adjusting diuretics as needed, monitoring hemodynamics/symptoms during and post physical therapy, and
increased risk for cardiac re-admission. Plan: Essential HTN (hypertension)
- No antihypertensive medications on file
-- SBP (systolic blood pressure) less than 140
-- Low salt diet advised
R1's physician progress note dated 5/20/2025, 4:25 PM, documents in part R1 has a PMHx (past medical
history) of COPD (chronic obstructive pulmonary disease), HTN (hypertension). Patient (R1) is drowsy,
oriented, calm. Patient reports headaches are improved with Candesartan. He also reports improvements
in back pain with medication, he believes this is due to relief of tension and anxiety from headaches.
Plan:
HEADACHES/MIGRAINES: Candesartan and monitor
HTN: Monitor off antihypertensives. Call doctor/nurse practitioner with SBP>170.
Facility document dated 06/18/23, titled guidelines for physician orders documents in part It is the policy of
the facility to follow the orders of the physician. All physician orders received pertaining to the resident will
be implemented and followed throughout the course of the resident's stay in the facility as the orders are
received.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145549
If continuation sheet
Page 2 of 2
