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BELHAVEN NURSING & REHAB CENTER

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BELHAVEN NURSING & REHAB CENTER VS
Nursing Homes USA
General
City Chicago  0.6% Nursing Homes USA have Chicago
State attribute explanation IL   5% Nursing Homes USA have IL
Street 11401 SOUTH OAKLEY AVENUE  
Zip Code 60643  
Phone 7732336311  
Overall Star Rating
3.11
Health Inspections Star Rating
2.83
Nurse Staffing Star Rating
3.17
Quality Measures Star Rating
3.31
RN Only Star Rating
3.17
Number of Certified Beds
221 
108.94
Total Number of Residents
195 
91.25
Percent of Occupied Beds
88 %
83.65 %
Health Survey Date 11/18/2011  
Fire Survey Date 12/8/2011  
Sprinkler Status Partially Sprinklered  8.5% Nursing Homes USA have Partially Sprinklered
Program Participation Medicare And Medicaid  91.5% Nursing Homes USA have Medicare and Medicaid
Type of Ownership For Profit - Corporation  56.7% Nursing Homes USA have For profit - Corporation
Located Within a Hospital? No  93.6% Nursing Homes USA don't have Located Within a Hospital?
Multi Nursing Home Ownership? No  45.1% Nursing Homes USA don't have Multi Nursing Home Ownership?
Resident and Family Councils Both  29.8% Nursing Homes USA have Both
Continuing Care Retirement Community? No  90.9% Nursing Homes USA don't have Continuing Care Retirement Community?
Quality Indicator Survey? No  68.7% Nursing Homes USA don't have Quality Indicator Survey?
Special Focus Facility? No  99% Nursing Homes USA don't have Special Focus Facility?
Civil Money Penalty Count
58.16
Total Enforcement Actions Count
56.31
# of deficiencies
20 
7.48
Staff Information
Number of Residents
195 
91.38
Number of RN Hours Per Resident Per Day
0.27 
0.77
Number of LPN/LVN Hours Per Resident Per Day
0.78 
0.84
Total Number of Licensed Staff Hours Per Resident Per Day
1.05 
1.59
Number of CNA Hours Per Resident Per Day
0.03 
5.49
Number Therapy Hours Per Resident Per Day
0.03 
0.10
Environmental Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.
survey Date: 09/20/2011
date Of Correction: 09/21/2011 
Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.
survey Date: 05/25/2011
date Of Correction: 06/01/2011 
Deficiency #3 Scope: Few
level Of Harm: 3
deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.
survey Date: 07/21/2009
date Of Correction: 08/06/2009 
Deficiency #4 Scope: Some
level Of Harm: 2
deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading.
survey Date: 06/15/2009
date Of Correction: 06/29/2009 
Deficiency #5 Scope: Few
level Of Harm: 2
deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.
survey Date: 06/15/2009
date Of Correction: 06/29/2009 
Mistreatment Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: 1) Hire Only People With No Legal History Of Abusing, Neglecting Or Mistreating Residents; Or 2) Report And Investigate Any Acts Or Reports Of Abuse, Neglect Or Mistreatment Of Residents.
survey Date: 07/15/2010
date Of Correction: 08/09/2010 
Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: 1) Hire Only People With No Legal History Of Abusing, Neglecting Or Mistreating Residents; Or 2) Report And Investigate Any Acts Or Reports Of Abuse, Neglect Or Mistreatment Of Residents.
survey Date: 11/24/2009
date Of Correction: 12/15/2009 
Deficiency #3 Scope: Few
level Of Harm: 3
deficiency: Write And Use Policies That Forbid Mistreatment, Neglect And Abuse Of Residents And Theft Of Residents' Property.
survey Date: 07/21/2009
date Of Correction: 08/06/2009 
Resident Rights Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Try To Resolve Each Resident's Complaints Quickly.
survey Date: 11/18/2011
date Of Correction: 12/02/2011 
Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident.
survey Date: 10/21/2010
date Of Correction: 11/01/2010 
Quality Care Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Provide Medically-related Social Services To Help Each Resident Achieve The Highest Possible Quality Of Life.
survey Date: 11/18/2011
date Of Correction: 12/02/2011 
Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.
survey Date: 11/24/2009
date Of Correction: 12/15/2009 
Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores.
survey Date: 10/14/2009
date Of Correction: 12/15/2009 
Deficiency #4 Scope: Few
level Of Harm: 2
deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.
survey Date: 10/14/2009
date Of Correction: 12/15/2009 
Deficiency #5 Scope: Few
level Of Harm: 2
deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.
survey Date: 07/21/2009
date Of Correction: 08/06/2009 
Deficiency #6 Scope: Few
level Of Harm: 2
deficiency: Assist Those Residents Who Need Total Help With Eating/drinking, Grooming And Personal And Oral Hygiene.
survey Date: 06/15/2009
date Of Correction: 06/29/2009 
Deficiency #7 Scope: Few
level Of Harm: 2
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 06/15/2009
date Of Correction: 06/29/2009 
Deficiency #8 Scope: Few
level Of Harm: 2
deficiency: Make Sure That Residents Receive Treatment/services To Not Only Continue, But Improve The Ability To Care For Themselves.
survey Date: 05/13/2009
date Of Correction: 06/02/2009 
Resident Assessment Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Allow The Resident The Right To Participate In The Planning Or Revision Of The Resident's Care Plan.
survey Date: 07/15/2010
date Of Correction: 08/09/2010 
Administration Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.
survey Date: 09/20/2011
date Of Correction: 09/21/2011 
Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication
25.1 %
25.09 %
Percent of long-stay residents whose need for help with daily activities has increased
75.2 %
32.95 %
Percent of long-stay residents who self-report moderate to severe pain
1.4 %
16.66 %
Percent of long-stay high-risk residents with pressure ulcers 11.6:1 % 
Percent of long-stay residents who lose too much weight
6.5 %
11.83 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder
24.7 %
44.54 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder
4.5 %
15.63 %
Percent of long-stay residents with a urinary tract infection
2.7 %
13.46 %
Percent of long-stay residents who have depressive symptoms
0.5 - 2.0 %
28.38 %
Percent of long-stay residents who were physically restrained
75.2 %
43.68 %
Percent of short-stay residents who self-report moderate to severe pain
15.8 %
25.02 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
64.7 %
84.64 %
Percent of short-stay residents with Pressure ulcers that are new or worsened
50 %
83.94 %
Percent of short-stay residents who newly received an antipsychotic medication
75.2 %
45.90 %
Percent of long-stay residents experiencing one or more falls with major injury
4.9 %
15.52 %
Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication 22.4:1 % 
Percent of long-stay residents whose need for help with daily activities has increased
75.2 %
23.70 %
Percent of long-stay residents who self-report moderate to severe pain
1.4 %
14.10 %
Percent of long-stay high-risk residents with pressure ulcers
9.7 %
9.22 %
Percent of long-stay residents who lose too much weight
8.3 %
8.50 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder
28.7 %
43.38 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder
6.8 %
10.65 %
Percent of long-stay residents with a urinary tract infection
4.5 %
9.58 %
Percent of long-stay residents who have depressive symptoms
0.5 - 2.0 %
19.86 %
Percent of long-stay residents who were physically restrained
75.2 %
38.53 %
Percent of long-stay residents experiencing one or more falls with major injury
4.8 %
10.73 %
Percent of short-stay residents who self-report moderate to severe pain
12.5 %
24.76 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
63.1 %
81.44 %
Percent of short-stay residents with Pressure ulcers that are new or worsened
55.2 %
74.75 %
Percent of short-stay residents who newly received an antipsychotic medication
14.3 %
17.34 %

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