Inspection·August 15, 2025

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 observation, interview, and record review, the facility failed to implement resident-directed care consistent with the resident's comprehensive assessment, professional standards of practice by a.) provide feeding assistance to two (R9, R10) residents b.) help a resident maintain their dignity during mealtime for one resident (R10) in a total sample of 10 residents. This failure places the resident at risk for more than minimal harm.Findings include:On 08/13/2025 at 12:49 PM, R10 sitting on a wheelchair, in the dining area, wearing a towel on his chest, falling asleep. R10 has a plate with pureed food covered with clear plastic in front of him on the table. Staffing seen passing out meal trays. On 08/13/2025 at 12:53 PM, R10 still positioned the same, falling asleep. One staff next to him, uncovered (plastic cover) the plate of pureed food and walked away with three other staff to pass out meal trays. R10 lifts his head a little, attempts to eat by himself, head is tilted to left side, with his right hand, grabbing food with spoon. R10 appears sleepy/drowsy, chin down, holding up spoon in the air and falling asleep. No staff providing feeding assistance to R10.On 08/13/2025 at 12:57 PM, R10 dropping food on the towel and eating with right hand, slowly. Some pureed food noted on his beard/chin area. Eating the small bowl of apple sauce with his mouth, without using a utensil. R10 grabbed spoon and filled with pureed food and place it in the mouth. With head down, falling asleep, appears with food still in his mouth. On 08/13/2025 at 1:01 PM, R10 falling asleep, no staff encouraging or standing next to R10. On 08/13/2025 at 1:02PM, R10's head tilting to his left again and forward. On 08/13/2025 at 1:03 PM, R10 picked up white bowl with a little bit of apple sauce and grabbed with mouth. On 08/13/2025 at 1:05 PM, R10 noted falling asleep, chin to chest. On 08/13/2025 at 1:07 PM, this surveyor questioned R10 how he was doing, R10 easily arousable, stated I need help with my food as saliva noted coming out of his mouth. On 08/13/2025 at 1:10 PM, R9 tilted towards his left side, eating with right hand, regular round spoon, eating dessert off from the plastic bowl, not able to use left hand. Approximately two spoonsful of turkey on the floor next to R9's bed, an assistive device plate noted. An empty cup of what appears like red color liquid (possibly juice) noted. No staff assisting resident eat his meal.On 08/14/2025 at 12:04 PM, R9 able to wheel himself, in the hallway. awake and responsive. Has a reclining wheelchair. On 08/14/2025 at 12:36 PM R10 sitting in front of the table, wearing glasses, wearing a hospital gown over his shirt. No lunch in front of him yet. R10's beard appears unclean, noted with light brown color particles (appears as dry food). On 08/14/2025 at 12:41 PM R10's head down, leaning forward. Staff member placed a lunch tray on the table in front of R10. R10 began to eat with his right hand using a spoon. R10 grabbed a spoonful of the pureed food, and some of the pureed landed on his left side of his mouth. R10 grabbed the chocolate pudding in a small bowl, lifted it up to his mouth and dropped some on his left finger/hand. No magic cup noted on R10's meal tray. No staff providing feeding assistance to R10. On 08/142025 at 1:01 PM V14 (Certified Nursing Assistant) observed another resident put some food on R10's finished plate. V14 removed Residents Affected - Few (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 3 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 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)