Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Beacon Hill during CMS and state inspections, most recent first.
Staff did not promptly inform a resident, the resident's doctor, and a family member about situations such as injury, decline, or room changes that affected the resident, as required by regulation.
A resident did not receive appropriate care for existing pressure ulcers, and preventive measures to avoid new ulcers were not consistently implemented. The facility did not follow established protocols for assessment, monitoring, and treatment of pressure ulcers.
The facility did not provide the required six daily servings of grains/breads on its menu for all residents, with multiple days showing missing servings across general and specialized diets. The Director of Nutrition Systems and the Dietitian confirmed the shortfall during review, despite facility policy and menu planning guidelines requiring nutritional adequacy and dietitian approval.
The facility did not have a complete or properly implemented water management plan for Legionella, as required by federal regulations. The only monitoring performed was infrequent water testing, with the last test conducted over a year ago. Essential elements such as flow diagrams, risk area identification, and control measures were missing from the plan, and there was no documentation of ongoing monitoring or interventions. All 40 residents were affected by this deficiency.
A resident with congestive heart failure did not have daily weights obtained and documented as ordered by the physician. The DON confirmed that staff did not follow the order, and facility policy required weights to be taken as prescribed.
A resident with multiple medical conditions and insomnia did not receive prescribed temazepam for two nights because the facility failed to obtain the required prescription in a timely manner. Nursing staff did not effectively communicate with providers to secure the necessary script, and the pharmacy did not receive the order, resulting in missed medication doses.
A resident with multiple medical conditions and recent abdominal surgery, who required maximum assistance for transfers, was manually transferred by two CNAs without the use of a mechanical lift, contrary to her care plan. This resulted in the resident sustaining a large bruise and a severe leg laceration requiring 29 staples. Staff interviews revealed inconsistent use of the mechanical lift and confusion about transfer protocols, while environmental hazards such as exposed metal edges contributed to the injuries.
The facility failed to provide timely medications to two residents, resulting in missed doses of prescribed supplements. One resident did not receive Magnesium Chloride-Calcium Carbonate for three days, while another missed Calcium-Vitamin D doses over two days. Documentation showed medications were unavailable, and the facility did not promptly address the issue, leading to a deficiency in pharmaceutical services.
The facility failed to prevent and manage pressure injuries for two residents, leading to the development and worsening of deep tissue injuries. One resident developed a heel injury that was not identified until it became unstageable, due to missed weekly skin assessments. Another resident's care plan for offloading heels was not consistently followed, resulting in a significant increase in the size of a heel injury. These deficiencies highlight lapses in adherence to the facility's protocols for pressure injury prevention and management.
The facility did not conduct an annual review of its Facility Assessment Tool, affecting all 35 residents. The last assessment was dated February 2023, and the Administrator acknowledged the oversight, stating that the review process was in progress. The facility's policy requires an annual review to evaluate resident needs and resources.
The facility failed to follow its Water Management plan, lacking necessary diagrams and assessments for Legionella prevention, and did not conduct required water testing since 2022. Additionally, staff did not use the required PPE for a resident on Enhanced Barrier Precautions, despite the care plan specifying gown and glove use during high-contact care.
The facility failed to maintain resident dignity by not covering urinary drainage bags for two residents. One resident with multiple diagnoses, including Alzheimer's, was observed with a visible urinary drainage bag containing cloudy urine. Another resident was also seen with a visible urinary drainage bag. The DON confirmed the need for covering these bags, as outlined in the facility's Dignity Policy.
A facility failed to address a resident's advance directive status upon admission. The resident, admitted with multiple health issues, had no code status listed in their electronic medical record until prompted by a surveyor. A FULL code status was entered on June 10, but the resident later requested a do not resuscitate status. The facility's policy mandates documentation of advance directives in clinical records.
A resident with multiple diagnoses, including dementia, did not have quarterly care plan meetings as required. The facility's records show a gap from August 2022 to January 2024 without a care plan meeting. The Social Service Director and Administrator acknowledged the lapse, citing issues with the scheduling process.
Two residents were not screened for or offered the pneumococcal vaccine upon admission, contrary to the facility's policy. The Infection Preventionist confirmed the oversight, noting that assessments should have been conducted within five days of admission.
The facility failed to screen and offer the COVID-19 vaccine to two residents, as required by their policy. One resident tested positive for COVID-19 during an outbreak but was asymptomatic. The Infection Preventionist confirmed the oversight, acknowledging that the residents were not screened or offered the vaccine upon admission.
The facility did not submit the MDS for three residents within the required timeframe. Although the assessments were completed, they were not transmitted to the State, exceeding the 28-day deadline. The MDS Coordinator was unsure why the submissions were delayed and acknowledged the oversight.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as mandated by regulations.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in the assessment, monitoring, and treatment of pressure ulcers for residents at risk. The report notes that necessary interventions to prevent skin breakdown were not consistently applied, and existing pressure ulcers were not managed according to established protocols.
Failure to Provide Required Daily Grain/Bread Servings on Facility Menu
Penalty
Summary
The facility failed to provide the required six servings of grains or breads daily on its menu for all 40 residents, as identified through review of the facility's Spring/Summer 2025 Diet Extensions for various diet types. Specific deficiencies were noted on each day of the week, with missing servings ranging from one to three for general diets and up to four for specialized diets such as Mechanical Soft, Pureed, Consistent Carbohydrate, and Heart Healthy. The Diet Type Report confirmed that 39 residents were receiving oral diets, and the menu audit checklist indicated the expectation of six daily grain servings. During interviews, the Director of Nutrition Systems and the Dietitian acknowledged that the menus were short on grain servings and confirmed that the menus were planned using USDA My Plate and state regulations. The facility's policy required menus to meet nutritional needs in accordance with national guidelines and to be approved by a dietitian or qualified nutrition professional. Despite these requirements, the menus did not consistently provide the mandated grain/bread servings for all diet types throughout the week.
Incomplete and Unimplemented Legionella Water Management Plan
Penalty
Summary
The facility failed to maintain a complete and compliant water management plan for Legionella, as required by federal regulations. The Director of Plant Operations confirmed that the only monitoring conducted was periodic water testing for Legionella, with the last test occurring over a year prior. The facility's water management plan was missing essential elements such as flow diagrams, identification of risk areas for Legionella growth, and specific control measures. Additionally, there was no documentation of monitoring or interventions related to control measures, and the plan did not include an assessment to identify where Legionella could grow and spread. The facility's policy required random testing of at least three water supply sources twice per year, but there was no evidence that this was being followed. The most recent Legionella water testing report recommended ongoing regular monitoring, but there was no documentation to show that water testing had been conducted since the last recorded date. The facility census at the time was 40 residents, all of whom were affected by the lack of a comprehensive and properly implemented water management plan.
Failure to Follow Physician Orders for Daily Weights in CHF Resident
Penalty
Summary
The facility failed to follow physician orders for a resident diagnosed with congestive heart failure by not obtaining and documenting daily weights as prescribed. The electronic medical record indicated that the resident, who had multiple diagnoses including congestive heart failure, was only weighed on three specific dates rather than daily as ordered. The Director of Nursing confirmed that daily weights were not performed, and the facility's own policy required weights to be taken and recorded according to physician orders. There was no documentation to show that the daily weights were completed as required for this resident.
Failure to Timely Obtain and Administer Ordered Medication
Penalty
Summary
The facility failed to ensure that medications were obtained and administered in a timely manner, resulting in a resident missing prescribed doses of temazepam for insomnia. The resident, who was cognitively intact and had multiple diagnoses including lumbosacral spinal fusion, lumbar spine stenosis, anxiety, and breast cancer, did not receive temazepam as ordered on two consecutive nights. Documentation in the electronic medical record and medication administration record confirmed that the medication was not available and had not been administered as prescribed. Nursing staff noted that a script was required for the pharmacy to fill the temazepam order, but there was a lack of effective communication and follow-up with the providers to obtain the necessary prescription. The pharmacy account manager confirmed that the medication was not on the resident's profile, indicating the script was never received. The administrator acknowledged that the process should not have taken over 24 hours, but the resident ultimately did not receive the medication as ordered due to these lapses.
Failure to Safely Transfer Resident and Prevent Accident Hazards
Penalty
Summary
A deficiency occurred when a resident with significant medical conditions, including encephalopathy, muscle weakness, congestive heart failure, morbid obesity, and recent abdominal surgery, was not safely transferred according to her assessed needs. The resident was documented as requiring maximum or total assistance for transfers and had a care plan indicating the use of a mechanical lift device with two staff for transfers. However, over multiple days, staff inconsistently used the mechanical lift, and on at least two occasions, the resident was manually transferred by two CNAs without the lift, despite her dependence and physical limitations. During these manual transfers, the resident sustained injuries. On one occasion, she developed a large bruise on her left leg, and on the following day, she suffered a significant laceration to the same area, requiring 29 staples at the hospital. Interviews with staff and family members confirmed that the mechanical lift was not used during these transfers, and there was confusion among staff regarding when the lift should be used. Documentation and care plans were inconsistent, and there was no clear assessment or directive specifying the use of the mechanical lift for this resident. Environmental hazards were also present in the resident's room, including an exposed metal wheelchair locking mechanism and an uncapped metal bed rail post, both of which were in close proximity to the resident during transfers. These hazards contributed to the injuries sustained. The facility's policy required the use of appropriate assistive devices and consistent transfer techniques, but these were not followed, and no assessment was documented to ensure the resident's safety during transfers.
Failure to Provide Timely Medication to Residents
Penalty
Summary
The facility failed to ensure timely procurement of medications for residents, resulting in missed doses as prescribed by physicians. Resident 1, who was admitted with multiple diagnoses including respiratory failure and type 2 diabetes, did not receive their prescribed Magnesium Chloride-Calcium Carbonate supplement for three consecutive days in February 2025. Documentation by various RNs indicated that the medication was not available, and at one point, a request was made to the resident's family to obtain the medication, which the Director of Nursing later confirmed was the facility's responsibility. Similarly, Resident 2, admitted with conditions such as sepsis and chronic kidney disease, missed doses of their prescribed Calcium-Vitamin D supplement over two days. The EMR showed that the medication was not available and was awaiting delivery or house supply. The Director of Nursing acknowledged that the order should have been changed sooner to a medication in stock to prevent missed doses. These incidents highlight the facility's failure to provide pharmaceutical services to meet the needs of each resident as required.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to identify and manage pressure injuries effectively for two residents, leading to the development and worsening of deep tissue injuries. Resident R34 was admitted with a blanchable redness in the sacral area and later developed a deep tissue injury on the left heel, which was not identified until it became unstageable. The facility's records show a lack of weekly skin assessments between May 8 and May 29, 2024, which contributed to the oversight. The wound was only documented on May 31, 2024, and by then, it had deteriorated significantly. The facility's protocol required regular skin checks and pressure-reducing interventions, which were not adequately followed. Resident R12 was admitted with multiple diagnoses, including sepsis and Alzheimer's disease, and was identified as at risk for pressure injuries. Despite care plans and treatment records indicating the need for offloading heels and regular repositioning, observations showed that R12's heels were not consistently offloaded, and the resident was found with heels directly on the bed. This lack of adherence to the care plan led to the worsening of R12's deep tissue injury, which increased in size significantly over a short period. The facility's wound care policy emphasized evidence-based practices, but these were not effectively implemented for R12. The facility's failure to adhere to its own policies and protocols for pressure injury prevention and management resulted in significant harm to both residents. The lack of timely assessments and interventions allowed the pressure injuries to develop and worsen, highlighting deficiencies in the facility's care practices. The wound care nurse and nurse practitioner acknowledged the lapses in protocol adherence, which contributed to the adverse outcomes for the residents.
Failure to Annually Review Facility Assessment
Penalty
Summary
The facility failed to ensure that their facility assessment was reviewed annually, affecting all 35 residents residing in the facility. The Resident Census and Condition report dated June 10, 2024, indicated a resident census of 35. However, the Facility Assessment Tool was last dated February 2023, indicating that it had not been reviewed within the required annual timeframe. During an interview on June 12, 2024, the Administrator acknowledged that the review process was underway but admitted that some tasks had been overlooked since he assumed his position at the end of January. The facility's policy, dated September 8, 2017, mandates an annual review of the facility-wide assessment, which includes evaluating the resident population and the resources needed for their care.
Inadequate Water Management and PPE Use
Penalty
Summary
The facility failed to maintain and follow its Water Management plan to detect and prevent waterborne pathogens, specifically Legionella. The Health Center Prevention and Control of Legionella policy lacked facility water flow diagrams or assessments to identify potential growth and spread areas for Legionella and other pathogens. The Director of Plant Operations, who was new to the role, was unaware of any measures in place to prevent Legionella and confirmed that the facility had not conducted the required water testing since 2022, despite the policy mandating biannual testing. Additionally, the facility did not ensure that staff donned the necessary personal protective equipment (PPE) for a resident on Enhanced Barrier Precautions. A resident with a urinary drainage device, colostomy bag, PICC, and a wound was not provided care with the required gown and gloves by the CNAs, who only wore gloves. The resident's care plan specified the need for gown and gloves during high-contact care, which was not adhered to, as confirmed by the Infection Control Nurse.
Failure to Cover Urinary Drainage Bags Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure residents were treated in a dignified manner by not covering urinary drainage bags for two residents. One resident, admitted with diagnoses including sepsis, urinary tract infection, and Alzheimer's disease, was observed on two occasions with a visible urinary drainage bag containing cloudy urine, which was visible from the hallway. Another resident was also observed on multiple occasions with a visible urinary drainage bag containing urine, also visible from the hallway. The Director of Nursing confirmed that urinary drainage bags should be covered for the dignity of the residents. The facility's Dignity Policy emphasizes the importance of promoting residents' well-being and self-esteem, prohibiting demeaning practices, and specifically mentions the need to cover urinary catheter bags.
Failure to Address Advance Directive Status Upon Admission
Penalty
Summary
The facility failed to address a resident's advance directive status upon admission, as evidenced by the case of a resident admitted on April 16, 2024, with multiple diagnoses including gastrointestinal hemorrhage, muscle weakness, and chronic diastolic congestive heart failure. Upon review on June 10, 2024, it was found that the resident's electronic medical record did not list a code status. The order recap summary indicated that no orders for the resident's code status were entered until June 10, 2024, after a POLST form was requested by the surveyor. An order for a FULL code status was entered on that date. The Social Service Director (SSD) confirmed that the code status should be addressed upon admission and acknowledged that the resident's code status was not addressed until June 11, 2024, when the resident expressed a preference for a do not resuscitate status. The facility's policy requires clear documentation of whether a client has executed an advance directive in their clinical record.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to conduct quarterly care plan meetings for a resident, identified as R26, who was admitted with diagnoses including dysphagia, muscle weakness, history of falling, and dementia. According to the resident's daughter and power of attorney, there was a year-long gap without any care plan meetings. The facility's records confirm that a care plan meeting was held on August 30, 2022, but the next documented meeting did not occur until January 29, 2024. The Social Service Director (SSD) acknowledged the absence of care plan meetings in 2023 and stated that the receptionist is now responsible for arranging these meetings. The facility's policy mandates that care plans be reviewed and updated quarterly, in conjunction with the required quarterly MDS assessment. The Administrator confirmed that there was a lapse in scheduling care plans due to issues within the social services department.
Failure to Screen and Offer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that residents were screened for and received the recommended doses of the pneumococcal vaccine. Specifically, two residents, identified as R31 and R17, were not screened for or offered the pneumonia vaccine upon their admission to the facility. R31's medical records from April 18, 2024, to June 11, 2024, and R17's records from April 11, 2024, to June 11, 2024, showed no documentation of screening or offering of the vaccine. This oversight was confirmed by the Infection Preventionist (IP), who acknowledged that both residents should have been screened and offered the vaccine. The facility's policy on pneumococcal vaccination states that all residents should be assessed for eligibility and offered the vaccine series within thirty days of admission. The policy also requires that assessments of vaccination status be conducted within five working days of admission if not done prior. However, the facility did not adhere to this policy for R31 and R17, as there was no documentation of any such assessment or offer of vaccination. The IP confirmed the lapse in procedure, indicating a failure in the implementation of the facility's vaccination policy.
Failure to Screen and Offer COVID-19 Vaccine to Residents
Penalty
Summary
The facility failed to ensure that residents were screened for and received all recommended doses of the COVID-19 vaccine. This deficiency was identified for two residents, R31 and R47, out of a sample of 14 residents reviewed for COVID-19 vaccination. R31 was admitted to the facility and had no documentation of receiving any COVID-19 vaccines as per the immunization report dated 6/5/24. Additionally, R31's medical records from 4/18/24 to 4/26/24 showed no evidence of being screened for or offered a COVID-19 vaccine. During a facility outbreak that began on 4/1/24, R31 tested positive for COVID-19 on 4/27/24 but was asymptomatic. Similarly, R47 was admitted to the facility, and their medical records from 5/10/24 to 6/11/24 showed no documentation of being screened for or offered a COVID-19 vaccine or booster. The Infection Preventionist (IP), identified as V5, confirmed that residents should be screened and offered the vaccine upon admission, and acknowledged that neither R31 nor R47 had been screened or offered the vaccine. The facility's policy dated 11/17/23 emphasized the importance of COVID-19 vaccine education, documentation, and reporting, which are overseen by the IP.
Failure to Timely Submit MDS for Residents
Penalty
Summary
The facility failed to ensure timely submission of Minimum Data Sets (MDS) for three residents, as required by regulations. The MDS for these residents were completed but not transmitted to the State within the mandated timeframe. Specifically, the quarterly MDS for three residents were marked as 'ready to export' but had not been sent, exceeding the 28-day submission requirement. The MDS Coordinator acknowledged the oversight and was uncertain why the MDS were not exported, noting that they were past due and not included in the MDS Accepted batch report.
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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.
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Nursing homes near Lombard
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bella Terra Lombard | 0.4 mi | ★★★★★ | 3 | 0 |
| The Pearl Of Downers Grove | 1.3 mi | ★★★★★ | 3 | 0 |
| Alta Rehab At Oak Brook | 2.8 mi | ★★★★★ | 6 | 0 |
| Oakwood Rehab And Nursing Center | 4 mi | ★★★★★ | 14 | 0 |
| Bella Terra Elmhurst | 4.1 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.