Federal inspection record · CMS data as of October 1, 2026
Belhaven Nursing & Rehab Center
11401 South Oakley Avenue, Chicago, IL · (773) 233-6311
- Cited for abuse (CMS abuse icon)
- Certified beds
- 221
- Residents per day
- 196
- Ownership
- For-Profit
- Chain
- Infinity Healthcare Consulting
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- April 1, 1986
1
How this home got 1 star
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Illinois.
-
Staffing
★★★★★no change (already 1)
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★1 of 5
Matches the rating CMS publishes on Care Compare.
This home carries CMS's abuse icon, which caps its inspection rating at 2 stars and so its overall rating at 4.
2
Where it sits among Illinois homes
Belhaven Nursing & Rehab Center carries 360 inspection points. That is fewer than 5% of Illinois's 659 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Illinois: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–31 pts
- 4★ 31–73 pts
- 3★ 73–120.25 pts
- 2★ 120.25–219 pts
- 1★ over 219 pts
Bars show every rated home in Illinois by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
110 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (10)
-
G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
-
G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
-
G
Provide safe, appropriate pain management for a resident who requires such services.
-
G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
-
G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Everything else, by area of care
Quality of Life and Care27E
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Resident Rights15F
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- D
Reasonably accommodate the needs and preferences of each resident.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Reasonably accommodate the needs and preferences of each resident.
- D
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.
- D
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.
- E
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.
- D
Reasonably accommodate the needs and preferences of each resident.
- D
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.
- D
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.
- E
Reasonably accommodate the needs and preferences of each resident.
- F
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Reasonably accommodate the needs and preferences of each resident.
- D
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.
- D
Reasonably accommodate the needs and preferences of each resident.
Nutrition and Dietary12F
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
- F
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F
Dispose of garbage and refuse properly.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- F
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.
- D
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.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F
Dispose of garbage and refuse properly.
Environmental11F
- F
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- E
Make sure that a working call system is available in each resident's bathroom and bathing area.
- F
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- D
Provide bedrooms that don't allow residents to see each other when privacy is needed.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- E
Make sure that a working call system is available in each resident's bathroom and bathing area.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- D
Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.
Pharmacy Service10E
- D
Ensure that residents are free from significant medication errors.
- D
Ensure that residents are free from significant medication errors.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure that residents are free from significant medication errors.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- E
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.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
- D
Ensure medication error rates are not 5 percent or greater.
- D
Ensure that residents are free from significant medication errors.
Freedom from Abuse, Neglect, and Exploitation10E
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Infection Control7F
- F
Provide and implement an infection prevention and control program.
- F
Implement a program that monitors antibiotic use.
- F
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- F
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
- F
Provide and implement an infection prevention and control program.
- F
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- F
Provide and implement an infection prevention and control program.
Resident Assessment and Care Planning4E
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Nursing and Physician Services3F
- F
Post nurse staffing information every day.
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Administration1D
- D
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Inspection history
2025-12-17
38 health deficiencies · 12 fire-safety deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (6 deficiencies)
2024-10-31
35 health deficiencies · 8 fire-safety deficiencies
Top issue: Quality of Life and Care (14 deficiencies)
2023-11-03
37 health deficiencies · 26 fire-safety deficiencies
Top issue: Quality of Life and Care (16 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 2 h 48 min of nursing staff time a day, 14 min of it from a registered nurse.
This home
2 h 48 min
Illinois average
3 h 28 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 41% of nursing staff and 63% of registered nurses left in the past year, along with 2 administrators.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$320,068 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-02-25 | Fine | $32,096 |
| 2025-01-03 | Fine | $113,764 |
| 2024-09-30 | Fine | $87,155 |
| 2024-09-30 | Payment Denial · 28 day denial | $0 |
| 2024-03-01 | Fine | $58,095 |
| 2024-03-01 | Payment Denial · 14 day denial | $0 |
| 2023-11-03 | Fine | $28,958 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.5 pts better | 1.5 | 2.0 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.1 pts better | 2.0 | 2.1 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine35.2 pts worse | 55.3% | 90.5% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine26.3 pts worse | 65.4% | 91.7% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury2.3 pts better | 0.7% | 3.0% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms43.3 pts worse | 99.2% | 55.9% | 13.5% |
| Percentage of long-stay residents who lose too much weight1.7 pts better | 4.4% | 6.1% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication13.6 pts better | 4.8% | 18.4% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication16.5 pts worse | 38.2% | 21.7% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened9 pts better | 3.8% | 12.8% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased10.4 pts better | 2.6% | 13.0% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladderAbout the same | 0.8% | 0.8% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection1.5 pts better | 0.0% | 1.5% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence5.1 pts better | 14.7% | 19.8% | 18.3% |
| Percentage of long-stay residents with pressure ulcers0.9 pts worse | 5.7% | 4.8% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine64.4 pts worse | 5.6% | 70.0% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit7.7 pts better | 5.8% | 13.5% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication11.8 pts worse | 14.0% | 2.2% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine53.2 pts worse | 10.0% | 63.2% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission0.2 pts better | 25.4% | 25.6% | 23.4% |
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Who owns and runs it
2 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| A&F Realty LLC | 5% Or Greater Direct Ownership Interest · Organization | 30% | 14 facilities |
| Birn, Phillip | W-2 Managing Employee · Individual | 0% | 3 facilities |
·
Fire safety
46 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke22F
- F
Have an enclosure around a vertical opening shaft.
- F
Inspect, test, and maintain automatic sprinkler systems.
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Install corridor and hallway doors that block smoke.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- F
Have an enclosure around a vertical opening shaft.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- E
Install an approved automatic sprinkler system.
- E
Install corridor and hallway doors that block smoke.
- D
Provide properly protected cooking facilities.
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
- F
Have an enclosure around a vertical opening shaft.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Install an approved automatic sprinkler system.
- F
Inspect, test, and maintain automatic sprinkler systems.
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Provide properly protected cooking facilities.
- E
Install a fire alarm system that can be heard throughout the facility.
- E
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
- E
Install corridor and hallway doors that block smoke.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Egress8F
- F
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- F
Install emergency lighting that can last at least 1 1/2 hours.
- D
Have properly located and lighted "Exit" signs.
- E
Have properly located and lighted "Exit" signs.
- F
Have properly located and lighted "Exit" signs.
- E
Meet other general requirements.
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- E
Have exits that are accessible at all times.
Services5F
- F
Have elevators that firefighters can control in the event of a fire.
- E
Install properly constructed and protected linen or trash chutes.
- E
Install properly constructed and protected linen or trash chutes.
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- E
Install properly constructed and protected linen or trash chutes.
Gas, Vacuum, and Electrical Systems5F
- F
Have generator or other power source capable of supplying service within 10 seconds.
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- F
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
- E
Ensure proper usage of power strips and extension cords.
Miscellaneous4F
- F
Have simulated fire drills held at unexpected times.
- F
Have restrictions on the use of flammable curtains.
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- E
Have restrictions on the use of portable space heaters.
Emergency Preparedness2F
- F
Establish staff and initial training requirements.
- F
Conduct testing and exercise requirements.
·
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- G
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- 5 h
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-
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-
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