Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Belvidere Health And Rehab during CMS and state inspections, most recent first.
Several residents with contractures and hemiparesis did not receive regular restorative assessments or consistent range of motion (ROM) services as required. One resident with a history of stroke and right-sided hemiplegia was observed with a contracted hand and no splint, and family members raised concerns about lack of therapy. Staff confirmed that restorative assessments and services were not provided as per facility policy, and documentation showed missed or insufficient restorative care for multiple residents.
A resident with multiple cardiac and chronic conditions experienced a decline, including refusal of meals, shortness of breath, and low oxygen saturation. Staff delayed full assessment and documentation, and communication with the NP was not properly recorded. The resident was eventually sent to the ER and admitted for a non-STEMI, but the facility did not follow its change of condition policy for timely identification and documentation.
A resident was given an antibiotic for a presumed UTI despite the facility not obtaining a urine analysis or laboratory confirmation of infection. The antibiotic was started based on symptoms of decreased energy, and both the NP and DON were aware that no urine specimen had been processed, yet the medication was administered for several days.
A resident was prescribed an antibiotic for a presumed UTI without laboratory confirmation, as the urine specimen was not picked up and no SBAR form or urinalysis was documented. Despite facility policies requiring antibiotic use protocols and monitoring, these steps were not followed, resulting in the resident remaining on antibiotics without confirmed indication.
A resident with a history of mental health issues and aggression physically assaulted another resident during a bingo event, resulting in a bleeding and bruised lip. The altercation was witnessed by a nurse, and the facility's abuse prevention policy was not effectively implemented to prevent the incident.
The facility experienced CNA staffing shortages on evening shifts from October to December 2023, affecting all residents. Despite a plan of correction, the facility struggled with retention and call-offs, leading to insufficient staffing levels. Administrative staff, including the DON and other CNAs, covered shifts when needed. The facility's policy required staffing based on resident needs, supplemented by outside agencies.
The facility failed to date multi-dose insulin pens upon opening and did not dispose of expired medications for several residents. Insulin pens were found without opening dates, making it impossible to determine their expiration. A multi-dose vial of insulin was also found expired in the medication cart. The facility's policies require recording the date opened and disposing of outdated medications, but these were not adhered to, leading to the deficiency.
A facility failed to document advance directives for a resident with multiple health conditions, including dementia and chronic kidney disease. The resident's Facesheet, Physician Order Sheets, and EMR lacked necessary advance directive information, and the care plan did not address this until after a surveyor's interview. Staff acknowledged the oversight, which was contrary to the facility's policy requiring documentation of advance directives upon admission.
A resident with a cast on his left arm was found restrained by a side rail, which he could not remove himself. The facility lacked a physician's order, Side Rail Assessment, and Restraint Assessment for the use of the side rail, which was acknowledged by staff as potentially being a restraint. The resident was a high fall risk, but the facility did not have a care plan addressing the use of side rails or restraints.
A resident with COPD and other health conditions was using oxygen without documented physician orders or care interventions. The facility's policy requires such orders, but none were found in the resident's records. Staff confirmed the absence of necessary documentation, highlighting a deficiency in ensuring safe and appropriate respiratory care.
A facility failed to ensure proper monitoring and care planning for a resident requiring dialysis. The resident's care plan lacked details related to dialysis treatment, and there was no documentation of site monitoring. Staff interviews revealed poor communication with the dialysis center and uncertainty about the resident's dialysis access and monitoring procedures. The facility's policy on hemodialysis was not followed, leading to deficiencies in care.
A facility failed to document and reconcile the administration of Tramadol for a resident, resulting in a discrepancy in the narcotic count. The resident's electronic medical record showed three doses were given, but the paper count sheet only documented two. The shift change sign-out report was blank for several shifts, indicating a failure to properly reconcile the narcotic count as per facility policy.
Failure to Provide Restorative Services and Assessments for Residents with Limited Mobility
Penalty
Summary
The facility failed to provide appropriate care and restorative services to maintain or improve range of motion (ROM) and mobility for several residents with physical limitations. One resident with a history of cerebral infarction and right-sided hemiplegia was observed with a contracted right arm and tightly closed fist, without any splint or device in place. Staff interviews confirmed that the resident was admitted with a contracted hand and had not been provided with a splint until occupational therapy was recently initiated, despite the last restorative assessment being over a year prior. The resident's family expressed concerns about the lack of exercises or therapy and the resident being in bed most of the time. The facility did not have a formal restorative program, and assessments were only conducted through the MDS process. Additionally, three other residents with documented hemiparesis and contractures were observed without evidence of regular restorative assessments or consistent provision of restorative services. Staff interviews indicated that restorative assessments should be completed quarterly and that services such as passive ROM should be provided every shift. However, records showed gaps in restorative minutes provided and missing assessments for the year. The facility's own policy stated that all residents would receive maintenance nursing services, but this was not consistently implemented for residents with physical limitations.
Failure to Timely Identify and Document Change in Condition
Penalty
Summary
The facility failed to identify and respond to a resident's change in condition in a timely manner. A female resident with a history of peripheral vascular disease, chronic heart failure, NSTEMI, atrial fibrillation, chronic kidney disease stage 3, hypertension, and muscle weakness was noted to have refused breakfast and lunch, consumed minimal fluids, and complained of not feeling well. She also reported shortness of breath, and her oxygen saturation was recorded at 89% on room air. Oxygen was applied, and Tylenol was administered for a mild fever. Two hours later, two nurses reassessed her and observed abdominal breathing and an irregular heart rate, prompting a call to the nurse practitioner and a decision to send her to the emergency room, where she was later admitted for a non-STEMI heart attack. Interview and record review revealed that the nurse did not document all assessments or communications with the nurse practitioner regarding the resident's condition. The nurse acknowledged that documentation was limited to a single progress note and that she should have documented more. The facility's policy requires prompt notification and documentation of significant changes in a resident's condition, including consultation with the physician and notification of the resident's representative, but this process was not fully followed in this case.
Antibiotic Administered Without Laboratory Confirmation
Penalty
Summary
A resident was prescribed and administered an antibiotic, Cefuroxime Axetil, for a presumed urinary tract infection (UTI) without laboratory confirmation of the infection. The resident exhibited decreased energy and was not acting like herself, prompting the facility to order a urine analysis (UA). However, due to repeated issues with the laboratory not picking up the urine specimen, no urinalysis results were obtained. Despite the absence of diagnostic confirmation, the resident was started on the antibiotic and received eight doses over several days. Progress notes and interviews confirm that both the nurse practitioner and the director of nursing were aware that the urine specimen had not been collected or processed, yet the antibiotic regimen was initiated and continued. The facility's policy requires that medications be administered only with adequate clinical indications, which was not met in this case as there was no documented evidence of a UTI or laboratory results to support the use of antibiotics.
Failure to Follow Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to follow its antibiotic stewardship program, resulting in a resident being prescribed an antibiotic for a presumed urinary tract infection (UTI) without confirmation of the infection. The resident's electronic medical record indicated that an antibiotic was started, and although a urine specimen was collected for analysis, it was never picked up by the laboratory. Despite the lack of laboratory confirmation, the resident continued to receive the antibiotic. During an interview, the DON stated that nurses use McGeer's criteria and an SBAR form to determine the need for antibiotics and that residents on antibiotics are monitored as part of the stewardship program. However, the resident's record did not contain a completed SBAR form or documentation of a urinalysis. Facility policies require the implementation of antibiotic use protocols and monitoring as part of the infection prevention and control program, but these protocols were not followed in this instance.
Failure to Protect Resident from Abuse During Bingo Event
Penalty
Summary
The facility failed to protect a resident, identified as R2, from abuse by another resident, R1. R1, who has a history of altered mental status, psychosis, and adjustment disorder, exhibited physical aggression towards R2 during a community bingo event. R1's care plan noted behavioral distress and aggression, including physical and verbal aggression, which were triggered by poor impulse control and mood instability. R2, who has delusional disorders and a history of mental health problems, was verbally aggressive and had a history of making inappropriate comments towards staff. During the bingo event, R1 struck R2 multiple times in the face following a verbal altercation, resulting in R2 sustaining a bleeding and bruised lip. The incident was witnessed by a registered nurse who intervened to separate the residents. The Director of Nursing confirmed the altercation and noted that R1's actions were willful and intentional. The facility's policy on abuse prevention emphasizes the protection of residents from abuse, including physical injury inflicted deliberately. Despite this policy, the facility did not prevent the altercation, which resulted in physical harm to R2. The report highlights the failure of the facility to protect R2 from abuse by another resident, as required by their abuse prevention program.
CNA Staffing Shortages in Evening Shifts
Penalty
Summary
The facility failed to ensure sufficient Certified Nursing Assistant (CNA) staffing from October through December 2023, which had the potential to affect all residents residing in the facility. The facility's assessment indicated that the evening shift required four CNAs, but the schedules showed that on multiple occasions during these months, only 2 to 2.5 CNAs were scheduled. This staffing shortage was acknowledged by the Director of Nursing (DON), who mentioned that the facility had a plan of correction in place and that administrative staff, including the Activity Director, Receptionist, and Dietary Manager, who are also CNAs, would cover shifts if needed. The Administrator confirmed that the facility struggled with maintaining staff for the evening shift, particularly at the end of 2023, due to call-offs and retention issues. Despite hiring efforts, only one new hire remained. The Administrator also noted that if administrative staff covered the floor, it was reported in the system, indicating that any staffing triggers were due to actual shortages. The facility's policy stated that staffing should be based on resident needs and supplemented by outside agencies if necessary.
Failure to Date Insulin Pens and Dispose of Expired Medications
Penalty
Summary
The facility failed to ensure that multi-dose insulin pens were dated when opened and did not dispose of expired medication for several residents. During an observation, five insulin pens belonging to different residents were found in a medication cart without the required date indicating when they were opened. The pens were labeled with a sticker stating they should be discarded after 28 days, but without the opening date, it was impossible to determine their expiration. A registered nurse acknowledged that the pens should have been dated upon opening, as they are only effective for 28 days. Additionally, a multi-dose vial of Fiasp insulin was found in the medication cart with an open date that indicated it was expired. The Director of Nurses confirmed that expired medications should be disposed of to prevent accidental use, as they may lose potency and effectiveness. The facility's policies require that the date opened be recorded on multi-dose vials and that no outdated medications be available for use, but these procedures were not followed, leading to the deficiency.
Failure to Document Advance Directives for Resident
Penalty
Summary
The facility failed to ensure that a resident had an order or care plan for advance directives. This deficiency was identified for one resident who was admitted with multiple diagnoses, including a left arm fracture, atrial fibrillation, stage 4 chronic kidney disease, diabetes, dementia, congestive heart failure, dysphagia, and depression. Upon review, it was found that the resident's Facesheet, which should have contained information about advance directives, was blank. Additionally, the resident's Physician Order Sheets and Electronic Medical Record (EMR) did not contain an order for advance directives or a scanned POLST form. The care plan also did not address advance directives until after the surveyor's interview with the Social Services Director. During interviews, a Registered Nurse and the Social Services Director both acknowledged the absence of advance directive information in the resident's records. The Registered Nurse explained that the facility's process involves entering advance directive orders into the EMR upon a resident's admission from the hospital, but this was not done for the resident in question. The Social Services Director admitted responsibility for the care plan and acknowledged that the necessary information was missing from the resident's chart. The facility's Advance Directives Policy requires that residents be informed of their rights to accept or refuse treatment and to formulate an advance directive, but this was not adhered to in this case.
Failure to Ensure Resident is Free from Restraints
Penalty
Summary
The facility failed to ensure that a resident, identified as R156, was free from the use of physical restraints. During observations on multiple occasions, R156 was found in bed with a side rail pulled up, which he could not remove himself due to his physical limitations. R156 had a blue cast on his left arm, rendering him unable to use it to grab the side rail, and he was observed making attempts to move in bed but was unable to sit up or reposition himself. The side rail was positioned in such a way that it could only be adjusted by someone outside the bed, effectively restraining R156. Interviews with facility staff, including CNAs and an RN, revealed that there was no physician's order for the use of side rails as restraints, nor was there a completed Side Rail Assessment or Restraint Assessment in R156's electronic medical record. Staff acknowledged that the side rail could be considered a restraint since R156 was unable to get out of bed on his own. The facility's policies required assessments and consent for restraint use, but these were not completed for R156. R156 was admitted to the facility with a history of falls and a broken arm, and he was identified as a high fall risk. Despite this, the facility did not have a care plan addressing the use of side rails or restraints for R156. The lack of proper assessments and documentation, as well as the absence of a care plan, contributed to the deficiency in ensuring R156 was free from unnecessary restraints.
Lack of Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to ensure that physician orders and interventions were in place for the administration of oxygen to a resident diagnosed with chronic obstructive pulmonary disease (COPD), atrial fibrillation, congestive heart failure, and the presence of a cardiac pacemaker. The resident, who was observed using oxygen at 1.5 liters per minute via a nasal cannula, did not have any documented physician orders or care interventions related to oxygen use in their medical records. The resident reported using oxygen at night and occasionally during the day while napping, but there was no formal documentation or care plan to guide this practice. A registered nurse and the Director of Nurses confirmed the absence of necessary physician orders and care interventions for the resident's oxygen use. The facility's policy on oxygen administration requires obtaining or reviewing a physician's order, which should include the flow rate and method of administration, as well as monitoring and documenting the resident's response to oxygen. The lack of these orders and interventions was identified as a deficiency, as oxygen is considered a medication that requires a physician's order to ensure safe and appropriate use.
Inadequate Dialysis Care and Monitoring for Resident
Penalty
Summary
The facility failed to provide adequate monitoring and care planning for a resident requiring dialysis treatment. The resident, who has a history of anoxic brain damage, chronic kidney disease, end-stage renal disease, hyperkalemia, acute kidney failure, and Type 2 Diabetes, was observed without a care plan related to her dialysis treatment. The facility's records lacked essential information, such as the name and contact details of the dialysis treatment center, and there was no documentation of monitoring the dialysis site in the electronic Treatment Administration Record (eTAR). Interviews with facility staff revealed a lack of communication and coordination with the dialysis center. The RN and DON admitted to not performing pre and post-treatment weights and not having emergency equipment at the resident's bedside. The staff also demonstrated uncertainty about the type of dialysis access the resident had and the necessary monitoring procedures. The facility's policy on hemodialysis was not followed, as it required the development and implementation of a care plan, assessment and documentation of the fistula or graft site, and obtaining post-dialysis weights, none of which were adequately addressed for the resident.
Failure to Document and Reconcile Narcotic Administration
Penalty
Summary
The facility failed to properly document and reconcile the administration of a narcotic medication for a resident, leading to a discrepancy in the narcotic count. The resident had an order for Tramadol HCl 50 mg to be administered every six hours for pain. During a review of the medication cart, it was found that the Tramadol card had 19 tablets remaining, while the count sheet indicated 20 tablets. The discrepancy was identified by a registered nurse during a shift change count, revealing that three doses had not been signed out on the previous shifts. The electronic medical record confirmed that the three doses were administered, with one dose given by an LPN during the PM shift and two doses given by a registered nurse during the night shift. However, the paper count sheet only reflected the two doses given by the night shift nurse, with no documentation for the dose given by the LPN. Additionally, the shift change sign-out report was blank for several shift changes, indicating a failure to properly reconcile the narcotic count. The facility's narcotic policy requires two nurses to count narcotics at the beginning and end of each shift, and any discrepancies should be reported immediately to the Director of Nurses.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 222 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Belvidere
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Symphony Northwoods | 0.5 mi | — | 16 | 0 |
| Symphony Maple Crest | 3.3 mi | — | 2 | 0 |
| Alden Debes Rehab & Hcc | 7.9 mi | — | 13 | 0 |
| Alden Park Strathmoor | 8.3 mi | — | 4 | 0 |
| Forest City Rehab & Nrsg Ctr | 8.3 mi | — | 18 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Belvidere Health And Rehab.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.