Inspection·December 17, 2025

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a comfortable environment for one resident (R140). This failure affected one resident (R140) reviewed for environmental concerns.Findings include:R140's diagnoses include but are not limited to paraplegia, osteomyelitis, pneumonia, pressure ulcer of sacral region, major depressive disorder, chronic kidney disease, peripheral vascular disease, anxiety.R140's Minimum Data Set, dated [DATE] has a Brief Interview for Mental Status score of 15, indicating R140's cognition is intact.Facility's resident council minutes dated 10/30/25 documents in part, R140 ask for maintenance to check his room [ROOM NUMBER]B.Facility's resident council minutes dated 11/20/25 documents in part, resident in room [ROOM NUMBER] asked if maintenance can stop by his room.On 12/15/25 10:51am surveyor and V13 (Maintenance Director) assessed multiple cracks in the window in room [ROOM NUMBER], R140's bedroom before discharge.On 12/15/25 at 10:51am V13 (Maintenance Director) stated that no one has told him that R140 wanted to see him. V13 stated that he was not told to do any work in room [ROOM NUMBER]. V13 stated that he does feel cold air coming from the window cracks in room [ROOM NUMBER]. V13 stated that a crack in the window with cold air coming through is considered an emergency. V13 stated that staff place work orders into the facility's computer system. V13 stated that he does not have any work orders for room [ROOM NUMBER].On 12/16/25 at 10:20am V45 (Wound care tech) stated that there was a time the R140 told him that R140 felt cold air coming from his window and that he was cold. V45 stated that he informed maintenance.On 12/16/25 at 11:17am V1 (Administrator) stated that it is expected for maintenance to respond to request as soon as possible. V1 stated that as soon as possible means as soon as they receive the request or within 24 hours of the request. V1 stated that it is not acceptable for a resident to have cold air blowing on them. V1 stated that the problem should be fixed, or the resident should be moved to a new area. V1 stated that he was not aware that R140 complained multiple times about a crack in his window.Facility's job description titled Maintenance Director documents in part, The Maintenance Director is held accountable for the decision making and carrying out the assigned duties and responsibilities for the overall operations of the maintenance department in accordance with current existing federal and state regulations and established company policies and procedures. Essential Duties/Responsibilities: Perform a variety of tasks on both the interior and exterior of buildings in accordance with mechanical, plumbing, EPA, and electrical codes and guidelines Respond to emergency maintenance and life safety needs promptly. E. Role Responsibilities-Resident Dignity: Ensure understanding of, and compliance with, all rules regarding residents' rights.:Facility's undated policy titled Resident Rights documents in part, As a resident of this facility, you have the right to a dignified existence and to communicate with individuals and representatives of choice. The facility will protect and promote your rights as designated below. Environment: the facility must provide a safe, clean, comfortable, home-like environment, allowing you the opportunity to use your personal (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 12/17/2025 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)