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Belhaven Nursing & Rehab Center

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Belhaven Nursing & Rehab Center is a for profit - individual facility in CHICAGO, IL with 221 certified beds and a 1-star overall CMS rating. The facility has 50 deficiency records on file. Total penalties: $320K.

11401 SOUTH OAKLEY AVENUE, CHICAGO, IL 60643

Phone: 7732336311

Overall Rating

1/5

Health Inspection

1/5

Staffing

1/5

Quality Measures

2/5

Long-Stay Quality

4/5

Facility Information

Provider Number
145549
Ownership
For profit - Individual
Provider Type
Medicare and Medicaid
Beds
221
Residents
190
In Hospital
No
County
Cook
Last Inspection
Oct 31, 2024

Staffing Data

RN Hours
0.22 (nat'l avg: 0.68)
LPN Hours
0.83
CNA Hours
1.87
Total Nursing Hours
2.93 (nat'l avg: 3.89)
PT Hours
0.01
Nursing Turnover
34.6%
RN Turnover
58.3%

What the CMS Record Reveals About Belhaven Nursing & Rehab Center

Belhaven Nursing & Rehab Center operates 221 certified beds in CHICAGO, IL with approximately 190 residents currently in care, and carries a CMS overall rating of 1 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (1★), and quality measures (2★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.

The inspection file contains 50 deficiency records from recent surveys, of which 9 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 5 penalties totaling $320K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 2.93 total nursing hours per resident day (national average 3.89), with RN coverage at 0.22 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.

Classified as "For profit - Individual" ownership and operating as a "Medicare and Medicaid" provider, Belhaven Nursing & Rehab Center falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 34.6%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.

Deficiency History (50 most recent)

D — Isolated - Minimal harm Dec 17, 2025 Tag: 0921

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Category: Environmental Deficiencies

Corrected: Jan 5, 2026

D — Isolated - Minimal harm Sep 18, 2025 Tag: 0806

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Category: Nutrition and Dietary Deficiencies

Corrected: Sep 19, 2025

F — Widespread - Minimal harm Aug 27, 2025 Tag: 0809

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.

Category: Nutrition and Dietary Deficiencies

Corrected: Sep 8, 2025

D — Isolated - Minimal harm Aug 27, 2025 Tag: 0760

Ensure that residents are free from significant medication errors.

Category: Pharmacy Service Deficiencies

Corrected: Sep 8, 2025

D — Isolated - Minimal harm Aug 15, 2025 Tag: 0808

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Category: Nutrition and Dietary Deficiencies

Corrected: Aug 19, 2025

D — Isolated - Minimal harm Aug 15, 2025 Tag: 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Category: Quality of Life and Care Deficiencies

Corrected: Aug 19, 2025

D — Isolated - Minimal harm Jul 3, 2025 Tag: 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Category: Quality of Life and Care Deficiencies

Corrected: Jul 18, 2025

E — Pattern - Minimal harm May 21, 2025 Tag: 0919

Make sure that a working call system is available in each resident's bathroom and bathing area.

Category: Environmental Deficiencies

Corrected: May 29, 2025

E — Pattern - Minimal harm May 4, 2025 Tag: 0584

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Category: Resident Rights Deficiencies

Corrected: May 7, 2025

D — Isolated - Minimal harm Apr 10, 2025 Tag: 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Category: Quality of Life and Care Deficiencies

Corrected: Apr 24, 2025

D — Isolated - Minimal harm Mar 16, 2025 Tag: 0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Category: Quality of Life and Care Deficiencies

Corrected: Mar 25, 2025

D — Isolated - Minimal harm Mar 5, 2025 Tag: 0919

Make sure that a working call system is available in each resident's bathroom and bathing area.

Category: Environmental Deficiencies

Corrected: Mar 25, 2025

G — Isolated - Actual harm Mar 5, 2025 Tag: 0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Category: Quality of Life and Care Deficiencies

Corrected: Mar 25, 2025

D — Isolated - Minimal harm Mar 5, 2025 Tag: 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Category: Quality of Life and Care Deficiencies

Corrected: Mar 25, 2025

D — Isolated - Minimal harm Mar 5, 2025 Tag: 0558

Reasonably accommodate the needs and preferences of each resident.

Category: Resident Rights Deficiencies

Corrected: Mar 25, 2025

D — Isolated - Minimal harm Feb 25, 2025 Tag: 0600

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Mar 5, 2025

E — Pattern - Minimal harm Jan 24, 2025 Tag: 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Category: Quality of Life and Care Deficiencies

Corrected: Jan 25, 2025

G — Isolated - Actual harm Jan 3, 2025 Tag: 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Category: Quality of Life and Care Deficiencies

Corrected: Jan 20, 2025

G — Isolated - Actual harm Jan 3, 2025 Tag: 0600

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Jan 20, 2025

D — Isolated - Minimal harm Oct 31, 2024 Tag: 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Category: Quality of Life and Care Deficiencies

Corrected: Nov 15, 2024

E — Pattern - Minimal harm Oct 31, 2024 Tag: 0921

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Category: Environmental Deficiencies

Corrected: Nov 15, 2024

F — Widespread - Minimal harm Oct 31, 2024 Tag: 0883

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Category: Infection Control Deficiencies

Corrected: Nov 15, 2024

F — Widespread - Minimal harm Oct 31, 2024 Tag: 0880

Provide and implement an infection prevention and control program.

Category: Infection Control Deficiencies

Corrected: Nov 15, 2024

F — Widespread - Minimal harm Oct 31, 2024 Tag: 0812

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Category: Nutrition and Dietary Deficiencies

Corrected: Nov 15, 2024

E — Pattern - Minimal harm Oct 31, 2024 Tag: 0761

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Category: Pharmacy Service Deficiencies

Corrected: Nov 15, 2024

E — Pattern - Minimal harm Oct 31, 2024 Tag: 0757

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Category: Pharmacy Service Deficiencies

Corrected: Nov 15, 2024

E — Pattern - Minimal harm Oct 31, 2024 Tag: 0755

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Category: Pharmacy Service Deficiencies

Corrected: Nov 15, 2024

D — Isolated - Minimal harm Oct 31, 2024 Tag: 0695

Provide safe and appropriate respiratory care for a resident when needed.

Category: Quality of Life and Care Deficiencies

Corrected: Nov 15, 2024

D — Isolated - Minimal harm Oct 31, 2024 Tag: 0690

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Category: Quality of Life and Care Deficiencies

Corrected: Nov 15, 2024

D — Isolated - Minimal harm Oct 31, 2024 Tag: 0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Category: Quality of Life and Care Deficiencies

Corrected: Nov 15, 2024

D — Isolated - Minimal harm Oct 31, 2024 Tag: 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Category: Quality of Life and Care Deficiencies

Corrected: Nov 15, 2024

D — Isolated - Minimal harm Oct 31, 2024 Tag: 0584

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Category: Resident Rights Deficiencies

Corrected: Nov 15, 2024

D — Isolated - Minimal harm Oct 31, 2024 Tag: 0578

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Category: Resident Rights Deficiencies

Corrected: Nov 15, 2024

G — Isolated - Actual harm Oct 24, 2024 Tag: 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Category: Quality of Life and Care Deficiencies

Corrected: Nov 15, 2024

D — Isolated - Minimal harm Oct 24, 2024 Tag: 0609

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Nov 10, 2024

E — Pattern - Minimal harm Oct 24, 2024 Tag: 0558

Reasonably accommodate the needs and preferences of each resident.

Category: Resident Rights Deficiencies

Corrected: Nov 10, 2024

G — Isolated - Actual harm Sep 30, 2024 Tag: 0697

Provide safe, appropriate pain management for a resident who requires such services.

Category: Quality of Life and Care Deficiencies

Corrected: Oct 17, 2024

G — Isolated - Actual harm Sep 30, 2024 Tag: 0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Category: Quality of Life and Care Deficiencies

Corrected: Nov 15, 2024

E — Pattern - Minimal harm Sep 30, 2024 Tag: 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Category: Quality of Life and Care Deficiencies

Corrected: Nov 15, 2024

D — Isolated - Minimal harm Aug 29, 2024 Tag: 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Category: Quality of Life and Care Deficiencies

Corrected: Sep 9, 2024

D — Isolated - Minimal harm Jul 12, 2024 Tag: 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Category: Quality of Life and Care Deficiencies

Corrected: Jul 25, 2024

D — Isolated - Minimal harm May 29, 2024 Tag: 0604

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Jun 12, 2024

G — Isolated - Actual harm Mar 25, 2024 Tag: 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Category: Quality of Life and Care Deficiencies

Corrected: Apr 11, 2024

G — Isolated - Actual harm Mar 25, 2024 Tag: 0600

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Apr 11, 2024

D — Isolated - Minimal harm Mar 1, 2024 Tag: 0776

Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.

Category: Administration Deficiencies

Corrected: Mar 15, 2024

G — Isolated - Actual harm Mar 1, 2024 Tag: 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Category: Quality of Life and Care Deficiencies

Corrected: Mar 15, 2024

D — Isolated - Minimal harm Jan 19, 2024 Tag: 0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Category: Quality of Life and Care Deficiencies

Corrected: Feb 2, 2024

D — Isolated - Minimal harm Jan 19, 2024 Tag: 0600

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Feb 2, 2024

E — Pattern - Minimal harm Dec 7, 2023 Tag: 0725

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Category: Nursing and Physician Services Deficiencies

Corrected: Dec 22, 2023

D — Isolated - Minimal harm Dec 7, 2023 Tag: 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Category: Quality of Life and Care Deficiencies

Corrected: Dec 22, 2023

Quality Measures

Measure Type Score Used in Rating
Percentage of long-stay residents whose need for help with daily activities has increased Long Stay 2.1% Yes
Percentage of long-stay residents who lose too much weight Long Stay 3.6% No
Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay 1.7% Yes
Percentage of long-stay residents with a urinary tract infection Long Stay 0.0% Yes
Percentage of long-stay residents who have depressive symptoms Long Stay 97.3% No
Percentage of long-stay residents who were physically restrained Long Stay 0.0% No
Percentage of long-stay residents experiencing one or more falls with major injury Long Stay 0.6% Yes
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine Long Stay 73.4% No
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine Short Stay 11.8% No
Percentage of short-stay residents who newly received an antipsychotic medication Short Stay 7.0% Yes
Percentage of long-stay residents whose ability to walk independently worsened Long Stay 1.9% Yes
Percentage of long-stay residents who received an antianxiety or hypnotic medication Long Stay 3.5% No
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine Long Stay 85.7% No
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine Short Stay 21.5% No
Percentage of long-stay residents with pressure ulcers Long Stay 7.4% Yes
Percentage of long-stay residents with new or worsened bowel or bladder incontinence Long Stay 19.1% No
Percentage of long-stay residents who received an antipsychotic medication Long Stay 32.9% Yes

Penalty History 5 penalties totaling $320K

Date Type Amount
Feb 25, 2025 Fine $32K
Jan 3, 2025 Fine $114K
Sep 30, 2024 Fine $87K
Sep 30, 2024 Payment Denial -
Mar 1, 2024 Fine $58K
Mar 1, 2024 Payment Denial -
Nov 3, 2023 Fine $29K

Frequently Asked Questions

What is the overall CMS rating for Belhaven Nursing & Rehab Center?
Belhaven Nursing & Rehab Center has an overall CMS rating of 1 out of 5 stars. This rating combines health inspection results (1★), staffing levels (1★), and quality measures (2★).
What are the staffing levels at Belhaven Nursing & Rehab Center?
Belhaven Nursing & Rehab Center reports 2.93 total nursing hours per resident day (national average: 3.89). RN hours are 0.22 per resident day (national average: 0.68). Nursing staff turnover is 34.6%.
How many beds does Belhaven Nursing & Rehab Center have?
Belhaven Nursing & Rehab Center has 221 certified beds with approximately 190 residents. The facility is located at 11401 SOUTH OAKLEY AVENUE, CHICAGO, IL 60643.
Does Belhaven Nursing & Rehab Center have any deficiencies on record?
Yes, Belhaven Nursing & Rehab Center has 50 deficiencies on record from recent inspections. Of these, 9 are classified as causing actual harm or jeopardy.
Has Belhaven Nursing & Rehab Center received any fines or penalties?
Yes, Belhaven Nursing & Rehab Center has received 5 penalties totaling $320K.
Who owns Belhaven Nursing & Rehab Center?
Belhaven Nursing & Rehab Center is classified as "For profit - Individual" ownership. The facility type is "Medicare and Medicaid".
When was Belhaven Nursing & Rehab Center last inspected?
The most recent health inspection for Belhaven Nursing & Rehab Center was on Oct 31, 2024. The facility received a health inspection rating of 1 out of 5 stars.
What quality measures are tracked for Belhaven Nursing & Rehab Center?
Belhaven Nursing & Rehab Center is evaluated on 17 quality measures, of which 8 are used in the CMS star rating calculation. These include measures for both long-stay and short-stay residents covering areas like infections, falls, pressure ulcers, and medication use.

Data Sources

Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.

Related

Data sourced from official U.S. government datasets. See our methodology for details. Retrieved and formatted by PlainNursing Editorial