Inspection·September 18, 2025

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview, and record review the facility failed to ensure residents received meal preferences and substitutes as requested. This failure affected 3 of 3 residents (R1, R2, R3) reviewed for meal preferences and substitutions. Findings Include:On 9/15/2025 at 1:46 pm, R1 stated he (R1) has informed staff several times that his dislikes should be noted on his meal ticket as ham, turkey, dressing, and oatmeal. R1 stated his meal ticket documents No Pork and he has informed staff that he eats pork but not ham. On 9/15/2025 at 1:31 pm, V7 (Certified Nurse's Assistant) stated residents are made aware of the meal substitutions every morning by the activity aide. V7 stated sometimes during mealtimes, a meal substitution will look appealing to a resident who has not requested a substitution meal, and the resident will make a request for that substitution. V7 stated the kitchen is being ran by a new company and the company's staff provides the wrong meals on the residents tray all the time. V7 stated a resident's dislikes are printed on the meal ticket and the kitchen will still add the disliked food item to the resident's tray. On 9/16/2025 at 9:16 am, R1 stated look at my tray, I have asked the staff to change my meal ticket, and the kitchen continues to put oatmeal on my tray. Surveyor observed oatmeal on resident's tray. Surveyor reviewed R1's meal ticket dated 9/16/2025 which documents, in part, Breakfast-Daily: Double Portions, Hot Cereal-Grits, No Pork. Dislikes/Do Not Serve-Sausage Patty (2oz). Special Instructions- No Pork.On 9/16/2025 at 9:19 am, V8 (Licensed Practical Nurse/LPN) stated the questions regarding a resident likes and dislikes are entered by the dietary staff. V8 stated R1 has reported his likes and dislikes to the nurses and the nurses has informed dietary. V8 stated if dietary doesn't correct the resident dislikes on the dietary meal ticket, then I (V8) should report it to the DON (Director of Nursing). R1's Face Sheet dated 9/16/2025 documents a diagnosis of but not limited to Paraplegic, Essential hypertension, Opioid Abuse, Personal History of Other Diseases of the Respiratory System, Anxiety Disorder, Encounter Attention to Colostomy, Contracture-Unspecified Joint, Abnormal Posture, Limitation of activities due to disability, Urinary Tract Infection, Other Intestinal Obstruction Unspecified as to Partial Versus Complete Obstruction, Other Malaise.R1's Minimum Data Set Section C dated 7/21/2025 documents, in part a BIMS (Brief Interview Mental Status) score of 15 which is indicative of an intact cognition.R1's Breakfast Meal Tray ticket dated 9/16/2025 documents Breakfast: Daily-Double portions, Hot Cereal-Grits, No Pork. Dislike/Do Not Serve Sausage Patty (2oz), Special Instructions-No PorkR1's Dietary order dated 9/8/2025 documents, in part, Breakfast: Cold Cereal or Grits ONLY!!!On 9/17/2025 at12:43 pm, R2's meal ticket has a dislike of peanut butter and jelly sandwiches and R2 received a peanut butter and jelly sandwich on her tray. On 9/17/2025 at 12:47pm, Surveyor observed R2 requested a cheeseburger substitute from V15 (Certified Nurse's Assistant-CNA). V15 verified R2's meal ticket documents a dislike of peanut butter and jelly sandwiches. V15 called dietary to request a cheeseburger. R2's Face Sheet dated 9/16/2025 documents a diagnosis of but not limited to Spastic Hemiplegia, Cerebral Palsy, Cerebral Infarction, (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 09/18/2025 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)