Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Belhaven Nursing & Rehab Center

CHICAGO, IL · 221 certified beds · Last Life Safety survey October 31, 2024

CMS Certification Number 145549 · first certified April 1986

Ownership

Operated by INFINITY HEALTHCARE CONSULTING · For profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within IL

46 citations — more than 96% of the 666 certified nursing homes in IL. Compared within IL rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 12 citations; the earlier surveys in the window averaged 17. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (September 2025 to December 2025), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was October 2024. Facilities in IL are typically surveyed 11–13 months after the last one (median 12), measured over 759 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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7 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

2 of the 46 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

19 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 46 Life Safety citations above. The Physical Environment Index

F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-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.
F-0880 Provide and implement an infection prevention and control program.
F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

How that compares

Citations on file over three years

Compared with the median facility in IL, and nationally. Surveyors differ markedly between states, so the IL figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	46
Median facility in IL	15
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
December 8, 2022	26
November 3, 2023	8
October 31, 2024	12

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0293	Have properly located and lighted "Exit" signs.	3	2024-10-31
K-0541	Install properly constructed and protected linen or trash chutes.	3	2024-10-31
K-0311	Have an enclosure around a vertical opening shaft.	3	2024-10-31
K-0363	Install corridor and hallway doors that block smoke.	3	2024-10-31
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	2	2024-10-31
K-0353	Inspect, test, and maintain automatic sprinkler systems.	2	2024-10-31
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	2	2024-10-31
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	2	2024-10-31

What the citations cover

Citations by CMS category

Smoke Deficiencies 22
Egress Deficiencies 8
Gas, Vacuum, and Electrical Systems Deficiencies 5
Services Deficiencies 5
Other 6

Citations by CMS category
Category	Citations
Smoke Deficiencies	22
Egress Deficiencies	8
Gas, Vacuum, and Electrical Systems Deficiencies	5
Services Deficiencies	5
Miscellaneous Deficiencies	4
Emergency Preparedness Deficiencies	2

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

October 31, 2024 — 12 citations

Citations issued on October 31, 2024
Tag	What the surveyor checks	Status
K-0222	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.	Deficient, Provider has date of correction (November 18, 2024)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (November 18, 2024)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (November 18, 2024)
K-0311	Have an enclosure around a vertical opening shaft.	Fire Safety Evaluation Survey (December 3, 2024)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (November 18, 2024)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (November 22, 2024)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (November 18, 2024)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (November 18, 2024)
K-0531	Have elevators that firefighters can control in the event of a fire.	Deficient, Provider has date of correction (November 22, 2024)
K-0541	Install properly constructed and protected linen or trash chutes.	Deficient, Provider has date of correction (November 18, 2024)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (November 18, 2024)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (November 18, 2024)

November 3, 2023 — 8 citations

Citations issued on November 3, 2023
Tag	What the surveyor checks	Status
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (November 24, 2023)
K-0311	Have an enclosure around a vertical opening shaft.	Fire Safety Evaluation Survey
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (November 24, 2023)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Waiver has been granted (January 10, 2024)
K-0351	Install an approved automatic sprinkler system.	Deficient, Provider has date of correction (November 24, 2023)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (November 24, 2023)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (November 24, 2023)
K-0541	Install properly constructed and protected linen or trash chutes.	Deficient, Provider has date of correction (November 24, 2023)

December 8, 2022 — 26 citations

Citations issued on December 8, 2022
Tag	What the surveyor checks	Status
E-0037	Establish staff and initial training requirements.	Deficient, Provider has date of correction (January 11, 2023)
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (January 11, 2023)
K-0200	Meet other general requirements.	Deficient, Provider has date of correction (January 11, 2023)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (January 3, 2023)
K-0271	Have exits that are accessible at all times.	Deficient, Provider has date of correction (January 3, 2023)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (January 20, 2023)
K-0311	Have an enclosure around a vertical opening shaft.	Fire Safety Evaluation Survey
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (January 3, 2023)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (January 20, 2023)
K-0341	Install a fire alarm system that can be heard throughout the facility.	Deficient, Provider has date of correction (January 20, 2023)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (February 13, 2023)
K-0351	Install an approved automatic sprinkler system.	Deficient, Provider has date of correction (January 11, 2023)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (January 20, 2023)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (January 3, 2023)
K-0361	Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.	Deficient, Provider has date of correction (January 3, 2023)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (January 11, 2023)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (January 11, 2023)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (February 13, 2023)
K-0541	Install properly constructed and protected linen or trash chutes.	Deficient, Provider has date of correction (January 11, 2023)
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	Deficient, Provider has date of correction (January 20, 2023)
K-0751	Have restrictions on the use of flammable curtains.	Deficient, Provider has date of correction (January 20, 2023)
K-0781	Have restrictions on the use of portable space heaters.	Deficient, Provider has date of correction (January 3, 2023)
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	Deficient, Provider has date of correction (January 20, 2023)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (January 20, 2023)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (January 3, 2023)
K-0926	Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.	Deficient, Provider has date of correction (January 20, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.