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Belhaven Nursing & Rehab Center

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About Belhaven Nursing & Rehab Center

General Information

Legal Business NameBelhaven Nursing And Rehabilitation Center LLC
Ownership TypeFor Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareApril 1, 1986 (31 years)
Capacity221
Residents185
Percent Occupied84%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsBoth
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Belhaven Nursing & Rehab Center

Belhaven Nursing & Rehab Center
was reviewed by Medicare to have a rating of 1 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of Illinois Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

October 29, 2015 - 13 months ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintKeep all essential equipment working safely.

October 9, 2015 - 14 months ago

 Residents AffectedSeveritySource/TypeDescription
CManyPotential for Minimal HarmHealth InspectionMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
DFewPotential for HarmHealth InspectionEnsure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
DFewPotential for HarmHealth InspectionKeep each resident free from physical restraints, unless needed for medical treatment.

October 8, 2015 - 14 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionAutomatic sprinkler systems that have been maintained in working order.
FManyPotential for HarmFire Safety InspectionProperly maintained smoke detectors.
FManyPotential for HarmFire Safety InspectionAn adequate water supply for the sprinkler system.
FManyPotential for HarmFire Safety InspectionPortable fire extinguishers.
FManyPotential for HarmFire Safety InspectionWeekly inspections and monthly testing of generators.
FManyPotential for HarmFire Safety InspectionProperly constructed linen or trash chutes.
FManyPotential for HarmFire Safety InspectionRecord of quarterly fire drills for each shift under varying conditions.
FManyPotential for HarmFire Safety InspectionA fire alarm system that can be heard throughout the facility.
FManyPotential for HarmFire Safety InspectionProper stairway enclosures and vertical shafts.
ESomePotential for HarmFire Safety InspectionWalls that prevent smoke from passing through and would resist fire for at least one hour.
ESomePotential for HarmFire Safety InspectionProper medical gas storage and administration areas.
ESomePotential for HarmFire Safety InspectionCorridor and hallway doors that block smoke.
ESomePotential for HarmFire Safety InspectionProperly installed electrical wiring and equipment.
ESomePotential for HarmFire Safety InspectionProperly located and lighted "Exit" signs.
ESomePotential for HarmFire Safety InspectionSpecial areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system.
ESomePotential for HarmFire Safety InspectionApproved construction type or materials.
ESomePotential for HarmFire Safety InspectionExits that are accessible at all times.
ESomePotential for HarmFire Safety InspectionExit stairways and towers that are smoke proof.
ESomePotential for HarmFire Safety InspectionAn approved automatic sprinkler system connected to the fire alarm system.
ESomePotential for HarmFire Safety InspectionProtected exits that allow the resident to escape the building.
DFewPotential for HarmFire Safety InspectionPosted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

September 10, 2015 - 15 months ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintGive each resident enough fluids to keep them healthy and prevent dehydration.
DFewPotential for HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

September 4, 2015 - 15 months ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintPrepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.
ESomePotential for HarmComplaintMake sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed.

August 12, 2015 - 16 months ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

July 23, 2015 - 17 months ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintHave a program that investigates, controls and keeps infection from spreading.

June 24, 2015 - 18 months ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

May 27, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
BSomePotential for Minimal HarmComplaintMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

May 21, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintPrepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.
ESomePotential for HarmComplaintAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
ESomePotential for HarmComplaintReasonably accommodate the needs and preferences of each resident.
DFewPotential for HarmComplaintGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.

April 22, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintReasonably accommodate the needs and preferences of each resident.
DFewPotential for HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

April 8, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

April 3, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintProvide medically-related social services to help each resident achieve the highest possible quality of life.

March 10, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintGive or get emergency care by a doctor 24 hours a day.
DFewPotential for HarmComplaintEnsure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
DFewPotential for HarmComplaintEnsure services provided by the nursing facility meet professional standards of quality.
DFewPotential for HarmComplaintImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

February 3, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintProperly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
DFewPotential for HarmComplaintEnsure services provided by the nursing facility meet professional standards of quality.

January 8, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintEnsure that residents are safe from serious medication errors.
DFewPotential for HarmComplaint1) 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.

November 6, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
ESomePotential for HarmHealth InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
ESomePotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
ESomePotential for HarmHealth InspectionOffer other nutritional food to each resident who will not eat the food served.
ESomePotential for HarmHealth InspectionEnsure that residents are safe from serious medication errors.
ESomePotential for HarmHealth InspectionDevelop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
ESomePotential for HarmHealth InspectionKeep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.
CManyPotential for Minimal HarmHealth InspectionMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
DFewPotential for HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
DFewPotential for HarmHealth Inspection1) 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.

October 31, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
DFewPotential for HarmComplaintDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

July 29, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintHave enough nurses to care for every resident in a way that maximizes the resident's well being.
ESomePotential for HarmComplaintAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
DFewPotential for HarmComplaintEnsure services provided by the nursing facility meet professional standards of quality.
DFewPotential for HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
DFewPotential for HarmComplaintGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
DFewPotential for HarmComplaintEnsure that residents are fully informed and understand their health status, care and treatments.

June 4, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmComplaintMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.

January 9, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
ESomePotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
ESomePotential for HarmHealth InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
ESomePotential for HarmHealth InspectionAllow residents the right to participate in the planning or revision of care and treatment.
ESomePotential for HarmHealth InspectionTry to resolve each resident's complaints quickly.
ESomePotential for HarmHealth InspectionProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
DFewPotential for HarmHealth InspectionDevelop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.

December 11, 2013 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
DFewPotential for HarmComplaintProvide medically-related social services to help each resident achieve the highest possible quality of life.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Belhaven Nursing & Rehab Center require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

2hr 5min
2hr 50min
ReportedExpected
CNA
50min
45min
ReportedExpected
LPN
25min
1hr 10min
ReportedExpected
RN
3hr 20min
4hr 50min
ReportedExpected
Total Nursing

This facility also provides approximately 15min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

72.4%
69.3%
69.3%
93.4%
Q1 2015Q2 2015Q3 2015IL
Assessed and Appropriately Given the Seasonal Influenza Vaccine
43.5%
37.6%
33.3%
92.3%
Q1 2015Q2 2015Q3 2015IL
Assessed and Appropriately Given the Pneumococcal Vaccine
68.4%
61.8%
67.1%
39.7%
Q1 2015Q2 2015Q3 2015IL
Low Risk Residents Who Lose Control of Their Bowel or Bladder
24.8%
27.0%
26.1%
22.5%
Q1 2015Q2 2015Q3 2015IL
Received an Antipsychotic Medication
18.8%
7.4%
2.3%
15.3%
Q1 2015Q2 2015Q3 2015IL
Need for Help with ADLs has Increased
0.0%
3.7%
3.9%
6.5%
Q1 2015Q2 2015Q3 2015IL
Self Report Moderate to Severe Pain
9.0%
9.3%
6.2%
8.1%
Q1 2015Q2 2015Q3 2015IL
Lose Too Much Weight
10.6%
12.3%
12.3%
6.4%
Q1 2015Q2 2015Q3 2015IL
High Risk Residents With Pressure Ulcers
3.3%
2.1%
13.3%
15.5%
Q1 2015Q2 2015Q3 2015IL
Have Depressive Symptoms
4.2%
1.9%
1.9%
4.9%
Q1 2015Q2 2015Q3 2015IL
With a Urinary Tract Infection
3.5%
4.2%
2.4%
3.2%
Q1 2015Q2 2015Q3 2015IL
Experiencing One or More Falls with Major Injury
4.8%
7.8%
5.7%
3.7%
Q1 2015Q2 2015Q3 2015IL
With a Catheter Inserted and Left in Their Bladder
1.2%
1.2%
1.8%
0.9%
Q1 2015Q2 2015Q3 2015IL
Were Physically Restrained

Quality Measures for Short Stay Residents

1.1%
3.4%
1.0%
78.7%
Q1 2015Q2 2015Q3 2015IL
Assessed and Appropriately Given the Pneumococcal Vaccine
13.1%
12.2%
12.2%
77.1%
Q1 2015Q2 2015Q3 2015IL
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
2.9%
2.9%
4.4%
15.3%
Q1 2015Q2 2015Q3 2015IL
Self Report Moderate to Severe Pain
3.7%
2.1%
2.0%
2.4%
Q1 2015Q2 2015Q3 2015IL
Newly Received an Antipsychotic Medication
1.6%
1.9%
1.6%
1.3%
Q1 2015Q2 2015Q3 2015IL
With Pressure Ulcers That Are New or Worsened