Health inspection·August 27, 2025

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated, that the same situation happened before with the evening nursing staff, sometimes this month, but R1 could not recall the exact date. R1 stated that R1 normally takes the seizure medication twice a day at 9 AM and around 5-6 PM. R1 was concerned and stated, that it is very important to take R1's seizure medications as per physician order, to prevent R1 from having seizures and when missed, there could be a probability that R1 could start having seizures again. On 8/25/2025 at 1:15 PM, observed V4 (LPN), sitting at the second-floor nurse's station, charting on computer. V4 stated that V4 start medication pass around 8 AM. On 8/26/025 at 8:30 AM, observed medication pass on the second-floor unit with V15 (Registered Nurse/RN). Observed V15 preparing R1's medications with no concerns. V15 used proper infection control and administered all R1's medications included but not limited to seizure medications. Observed V15 passed R1's morning medications that consisted of Amlodipine 5mg tablet daily; Lipitor 20mg daily; Keppra 1000mg twice a day; Lisinopril 10mg daily; Phenobarbital 100 mg twice a day; Pregabalin 200mg twice a day; Vitamin B1 100mg daily, Folic Acid 1mg daily, Aspirin 81mg daily and Famotidine 20mg daily. On 8/26/2025 at 09:05 AM, observed V3 (RN) at the nurse's station on the second-floor documenting. V3, stated, that V3 already administered all R2's medication this morning around 8:20 AM. Observed V3 pulling all R2's medications from the medication cart assigned to R2's hallway. V3 stated, that the medications administered to R2 this morning, included but not limited to Candesartan , Tamsulosin, Docusate Sodium, Folic Acid, Multivitamin with Minerals, Albuterol inhaler, Advair Diskus Inhalation Aerosol, Fluticasone Nasal spray and inhaler, Tiotropium Bromide inhalation capsule. Observed R2's medications, including inhalers in a plastic bag with R2's name on it, and inside each medication was properly dated and labeled with pharmacy labels that showed R2's information. V3 stated that if a medication would not be administered for any reason, such as resident refusal, it should be documented in EMAR with a code specific to the reason for not administrating the medication. The EMAR block should not be left blank, because did other nurse would not know a medication was administered.On 8/26/2025 at 10:47 am, V2 (Director of Nursing/DON) stated, that medications, should be administrated to residents exactly as ordered by the physician. V2 also stated, that the nurses should follow facility's medication administration policy and call doctor if medication was not given. V2 stated, that when medication is administered, the task should be documented in the electronic medication administration record (EMAR) by the nurse. The given mediation would show a checkmark code in the appropriate medication administration box. V2 also stated, that if resident refused to take medication, there would be a code number 2 in the administration box and that the different codes for omitting medications are displayed on each page of EMAR. On 8/26/2025 at 10:51 AM, V2 (DON) investigated the EMAR and affirmed that R1's seizure medications were not documented as administered, refused, or omitted for other reason, by the nurses on 8/11/2025, 8/15/2025 and on 8/17/2025. V2 could see in the nurse's notes any documentation stating the reason why medications were not given. V2 affirmed that R1's seizure medications were not administered on three different dates and shift times. V2 stated that the nurses should be documenting all medication administration opportunities and affirmed that V13 (LPN) and V4 (LPN) were the nurses, caring for R1 on the dates mentioned. V2 stated, that the consequences of not administering seizure and other prescribed medications as ordered, could cause R1 to have a high probability of having a seizure and could otherwise cause potential harm to the resident. On 8/26/2025 at 11:30 AM, V13 (LPN), via phone conversation, while V2 present, stated, that R1 received all medications, and that V13 did not document the administration of the medications to R1. V13 stated the understanding, that missing documentation of administering medications, shows in audits as medications not administered and with no documented reason why held. On 8/26/2025 at 11:40 AM, V2 (DON), stated that V13 (LPN), and V4 (LPN) should be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145549 If continuation sheet Page 2 of 6 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 08/27/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few charting medication administration. V2 also stated, that V2 is familiar with R1 and stated that R1's behavior changes quickly and is known to have manipulative tendencies. V2 affirmed the understanding, that missing documentation of administering medications, shows in audits as medications not administered. On 8/26/2025 AT 1:00 PM, V14 (Registered Pharmacist, Director of Clinical services consultant ) stated, that the consequences of omitting or missing a dose of a seizure medications is that depending on individual's health status and severity of seizure disorder, the resident could potentially have seizures. V14 stated that , R1 has seizure medications ordered as prevention of seizures.On 8/26/2025 at 4PM, V4 (LPN) said, that V4 was taking care of R1 and that V4 remembers R1 refusing all medications on 8/11/25. V4 said, that the refusal should be documented in EMAR with a code of 2 and thinks that V4 documented the refusal in the EMAR. V4 also said, that if there are empty spaces in the EMAR under all medications, that V4 probably forgot to document the medication refusal in the computer and said . because there was so much going on . V4 affirmed the understanding, that missing documentation of administering medications, shows in audits as medications not administered. On 8/26/2025 at 4:30 PM, V2 stated, that there are three medication carts serving on the second-floor unit. The medication carts are named The East Medication Cart, The [NAME] Medication Cart and The Split Medication Cart. The Split medication cart served 26 residents. V2 stated, that each cart has medications stocked specifically only for those residents that the cart serves, and the carts would not be containing other resident's medications. R1's Physician's order summary report, (8/8/2025) showed in part, active orders from 7/21/2025 for medications included but not limited to: Amlodipine Besylate oral tablet 5mg, give 1 tablet by mouth once a day for hypertension (HTN); Aspirin tablet 81mg, give 1 tablet by mouth once a day for HTN; Atorvastatin Calcium oral tablet 20mg, give one tablet by mouth once a day for HTN; Famotidine oral tablet 20mg, give one tablet by mouth once a day for ulcer; Folic Acid oral tablet 1mg, give one tablet by mouth once a day for supplement; Levetiracetam oral tablet 1000mg, give 1 tablet by mouth twice a day for seizure; Lisinopril oral tablet 10mg, give one tablet by mouth once a day for HTN; Phenobarbital oral tablet 100mg, give 100mg by mouth twice a day for seizures; Pregabalin oral capsule 200mg, give 200 mg by mouth two times a day for seizures; Thiamine HCL oral Tablet 100mg, give one tablet by mouth once a day for supplement; and Trazodone HCl oral tablet 150mg, give one tablet by mouth once a day for antidepressant.R1's electronic medication administration record (EMAR), documents, in part, on 8/11/2025 empty spaces under 9am medications including but not limited to: Amlodipine Besylate oral tablet 5mg, Aspirin tablet 81mg, Atorvastatin Calcium oral tablet 20mg, Famotidine oral tablet 20mg, Folic Acid oral tablet 1mg, Levetiracetam oral tablet 1000mg, Lisinopril oral tablet 10mg, Phenobarbital oral tablet 100mg, Pregabalin oral capsule 200mg, Thiamine HCL oral Tablet 100mg, and Trazodone HCl oral tablet 150mg. Observed empty spaces under 8/15/2025 at 6 PM for Pregabalin 200mg and Trazodone 150mg for 9 PM. Observed empty spaces under 8/17/2025 Levetiracetam 1000mg and Phenobarbital 100mg for 5 PM, Pregabalin 200mg for 6 PM and Trazodone 150mg for 9 PM. The empty spaces were without a checkmark code or any other code documenting if R1's medications were held, refused, or administered. On 8/25/2025 reviewed facility's Daily Staffing Schedule for the month of August 2025, and observed that on 8/11/2025 during AM shift, V4 (Licensed Practical Nurse/LPN) was working on the second-floor unit and took care of R1. Observed on 8/15/2025 during PM and Night shift, and on 8/17/2025 during PM shift, V13 (LPN) was caring for R1.R1's care plan (7/21/2025) documents, in part that R1 is at risk for seizure activity, R1s seizure activity should be controlled with medication and to administer medication as directed and follow pharmaceutical recommendations.R1's progress notes, showed a medical professional note (8/13/2025) that documents in part, R1 denies new seizure activity, but stated that if not taking R1's seizure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145549 If continuation sheet Page 3 of 6 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 08/27/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete medication, R1 could experience potential seizure. Progress notes documents in part, that R1 has past medical medication history includes Levetiracetam for seizures, phenobarbital and pregabalin for seizures. Progress notes also documents in part, that R1's treatment plan is to continue all seizures medications and that 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 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. Event ID: Facility ID: 145549 If continuation sheet Page 4 of 6 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 08/27/2025 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 Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on observation, interview, and record review, the facility failed to ensure that residents were provided meals and snacks at appropriate times, in accordance with 42 CFRS483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. These failures have the potential to affect all 199 residents who receive oral meals from the facility's kitchen. Findings Include:On 08/25/2025 at 09:45 AM Surveyor was provided with facility census listing 199 residents residing in the facility.On 08/25/2025 at 1:00pm surveyor observed the Dining Rooms on the 2nd floor that revealed:Food Carts had been brought to the 2nd Floor Dining so staff could start the lunch meal service. Residents had been sitting at the tables waiting for food trays to be passed out. Only some residents received food trays because staff was waiting for the rest of the meals to be sent up from the kitchen.On 08/25/2025 at 1:00pm V16(Certified Nursing Assistant/CNA) said since the new company has taken over kitchen duties food has been sent up the units late. V16(CNA) said she thinks they are short staffed in the kitchen, but it has been an issue with getting meals on the units so they can start at scheduled meals times.On 8/25/2025 at 1:05pm R5 stated the food comes late all the time and they are not doing anything about it. R5 said he has voiced his concerns to staff and during resident council meetings but it hasn't improved the fact that lunch is always served lateOn 08/25/2025 at 1:20pm surveyor observed the 1st Floor Dining room that revealed:Residents sitting at tables eating lunch and being assisted by staff. Surveyor observed cheese pizza, veggies, tots, cup of pineapples being served as stated on the monthly food menu.On 08/25/2025 at 1:25pm V12(Central Supplies) said lunch has been coming late to the 1st Floor Unit, it's supposed to come at 12:00pm and at 12:50pm they were still waiting for food trays. V12(Central Supplies) said she normally assist on the 3rd Floor Dining Room and she's not even sure they received their meals yet.On 08/25/2025 at 1:40pm V10(Restorative Aid) said for the last two weeks she has noticed that food is coming up late from the kitchen. V10(Restorative Aid) said it's mainly lunch that comes is the problem, that they might be short staffed in the kitchen so they run behind getting food out on-time.On 08/26/2025 at 8:50am surveyor observed the kitchen with V9(Dietary Director), walk-in fridge was 39 degrees Fahrenheit, freezer 9 degrees Fahrenheit, dry goods items stored and labeled within expiration dates. No signs of trash on the floor or evidence of pest. No concerns with cleanliness or issues with the kitchen being dirty.On 08/26/2025 at 9:00am V9(Dietary Director) said the goal is to have food up to the units so the dietary aids could begin meal services as scheduled. V9(Dietary Director) said breakfast should begin at 8:00am, lunch 12:00pm, and dinner at 5:00pm per the mealtimes schedule posted. V9(Dietary Director) said he only started two weeks ago and is aware that the kitchen has been running behind schedule and sending food out late to the units. V9(Dietary Director) said he's trying to address the issues voiced by residents and is in the process of hiring more kitchen staff. On 08/26/2025 at 11:00am V5(Assistant Director of Nursing/ADON) said she is aware of resident concerns about meals being sent out late from the kitchen, V5(ADON) said the kitchen is run by an independent vendor and they have voiced their concerns to corporate and upper management about the issues they facility is having with the kitchen. V5(Assistant Director of Nursing/ADON) on multiply occasions she has spoken to residents about how late food trays are getting to the units and something needs to be done about the issue. V5(ADON) said it's out of their control since the new vendor has taken control of kitchen duties.On 08/26/2025 at 12:55pm surveyor observed 1st Floor Dining Room, no food trays (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145549 If continuation sheet Page 5 of 6 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 08/27/2025 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. Event ID: Facility ID: 145549 If continuation sheet Page 6 of 6