Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Bella Terra Elmhurst during CMS and state inspections, most recent first.
Two residents with significant medical needs, including dysphagia and blindness, did not receive the required one-to-one feeding assistance as documented in their care plans and physician orders. One was observed eating with her hands without staff help, while another was left calling for help with an untouched meal tray. Staff confirmed the lack of timely assistance despite facility policy and mealtime schedules.
A resident with multiple health issues, including dementia and malnutrition, was not properly monitored for bowel movements, resulting in severe constipation and rectal bleeding. Despite alerts in the EMR, staff failed to assess and intervene, leading to the resident's hospitalization for a blood transfusion and emergency treatment. The facility's policy on bowel management was not adhered to, contributing to the deficiency.
A resident with multiple diagnoses experienced unrelieved gastrointestinal symptoms for 24 hours, leading to self-initiated hospital transfer and treatment for sepsis. Despite persistent symptoms, facility staff failed to notify the physician, assuming symptoms were manageable with standing orders. The facility's records lacked documentation of physician notification or adequate assessment, contrary to policy.
The facility failed to follow its policy to immediately consult with a resident's physician and notify a resident's representative when a resident had a change in condition requiring transfer to the hospital. This deficiency was identified in two residents who experienced significant changes in their health status without timely notification to their physicians or family members.
The facility failed to respond adequately to a grievance regarding missing items for a resident. Despite multiple follow-ups by the resident's daughter, the facility did not provide a resolution or complete a grievance form as required by their policy. The administrator acknowledged receiving the grievance but did not take appropriate action to resolve the issue in a timely manner.
A resident with multiple diagnoses, including heart failure, was not administered ordered oxygen despite complaints of shortness of breath. The Agency RN on duty did not follow the standing order for oxygen, leading to the resident's transfer to the hospital the following morning.
Failure to Provide Required Feeding Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide required feeding assistance to two dependent residents, both of whom had documented needs for one-to-one feeding support due to significant medical conditions. One resident, an elderly female with dementia, partial paralysis from a stroke, dysphagia, and other chronic conditions, had active physician orders and care plans specifying the need for one-to-one feeding assistance during all meals. Despite these orders, she was observed eating pureed food with her bare hands without any staff assistance present. The Director of Nursing confirmed that this resident required one-to-one feeding assistance to prevent aspiration or choking. Another resident, who was blind and dependent on staff for all activities of daily living, was found calling for help in her room with her breakfast tray untouched. She expressed hunger and a desire to eat, but no staff were present to assist her. The assigned CNA stated she had not yet fed the resident due to helping another staff member, and the RN confirmed the meal had not been started. The facility's mealtime schedule indicated that breakfast should have been served and assistance provided much earlier. The Director of Nursing stated that residents requiring one-to-one feeding assistance should be fed within 15 minutes of tray delivery, which did not occur in these cases.
Failure to Monitor Bowel Movements Leads to Resident Hospitalization
Penalty
Summary
The facility failed to adequately assess and monitor a resident, identified as R1, who had no recorded bowel movement for eight consecutive days and was experiencing abdominal discomfort. This oversight led to R1 suffering from acute rectal bleeding, necessitating hospitalization for a blood transfusion and emergency intravenous medication to counteract the effects of her blood thinner. Additionally, R1 required the insertion of a rectal tube to manage fecal impaction. R1's medical history included dementia, psychosis, severe protein caloric malnutrition, anxiety, depression, diabetes type 2, hypertension, and hyperlipidemia. Despite being moderately cognitively impaired and always incontinent of bowel, requiring substantial assistance with toileting, the facility did not respond to alerts indicating no bowel movement for multiple days. The care plan for R1, initiated on 9/21/2024, identified her as at risk for constipation due to decreased mobility and medication effects, yet the facility failed to implement necessary interventions. Interviews with staff revealed a lack of communication and understanding of bowel movement documentation and alerts. CNAs documented bowel movements in the EMR, but nurses did not consistently review these records or respond to alerts. The facility's policy required CNAs to document bowel activity every shift and nurses to check triggered alerts, but these procedures were not followed, leading to R1's severe medical condition and subsequent hospitalization.
Failure to Notify Physician of Resident's Acute Symptoms
Penalty
Summary
The facility failed to consult with a resident's physician when the resident experienced unrelieved acute gastrointestinal symptoms for 24 hours. This oversight led to the resident, who had multiple diagnoses including gastro-esophageal reflux disease and chronic obstructive pulmonary disease, calling emergency paramedics herself for hospital transfer. The resident was subsequently hospitalized for treatment of sepsis related to acute enterocolitis and aspiration pneumonia. The report details that the resident began experiencing symptoms of diarrhea and nausea during the night shift, and was administered as-needed medications by the attending RN. However, the RN did not contact the resident's physician, assuming the symptoms were manageable with standing orders. The symptoms persisted into the next shift, with the resident vomiting multiple times and appearing ill, yet the RN on duty also failed to notify the physician, assuming the symptoms were due to overeating chocolates. The facility's records lacked documentation of physician notification or adequate assessment of the resident's ongoing symptoms, contrary to the facility's policies on change of condition and notification. The resident's condition deteriorated, leading her to call 911 for assistance, and upon hospital arrival, she was treated for severe conditions including sepsis and aspiration pneumonia. The facility's failure to adhere to its policies resulted in a significant oversight in the resident's care.
Failure to Notify Physician and Family of Resident's Change in Condition
Penalty
Summary
The facility failed to follow its policy to immediately consult with a resident's physician and notify a resident's representative when a resident had a change in condition requiring transfer to the hospital. This deficiency was identified in two residents. The first resident (R2) was admitted with multiple diagnoses including heart failure and cerebrovascular disease. On the night of 4/16/2024, R2 experienced shortness of breath and requested oxygen, but the attending nurse did not have an order for it and did not contact a physician. The resident's condition persisted until the next morning when another nurse administered oxygen and the resident was subsequently transferred to the hospital. There was no documentation of the overnight assessment or oxygen saturation levels for R2 during this period. The second resident (R1) was admitted with multiple diagnoses including a history of falls and malnutrition. On 12/11/2023, R1 was found to be confused and was transferred to the hospital without notifying the resident's daughter. The nurse responsible for R1 admitted to being too busy to make the call. The resident's daughter discovered the transfer when she visited the facility later that day. R1 was hospitalized for acute encephalopathy possibly due to an infection. The facility's policy requires immediate notification of the resident, their physician, and their legal representative or family member in the event of a significant change in condition, which was not followed in these cases.
Failure to Address Grievance Regarding Missing Items
Penalty
Summary
The facility failed to respond adequately to a grievance regarding missing items for a resident. The resident's daughter reported the missing cell phone and hearing aids to the facility on multiple occasions, starting on January 7, 2024. Despite attempts by the Guest Service Director and Medical Records Staff to locate the cell phone, it was not found. The daughter continued to follow up with the facility through emails and phone calls, but the facility did not provide a resolution or complete a grievance form as required by their policy. The facility's administrator acknowledged receiving the grievance but did not follow up with the resident's daughter or take appropriate action to resolve the issue in a timely manner. The facility's grievance policy requires that all written grievance decisions include specific details and be issued promptly. However, in this case, 71 days passed without the resident's daughter receiving a resolution to her grievance. The facility's failure to adhere to its grievance policy and promptly address the concerns of the resident's daughter resulted in a deficiency in honoring the resident's right to voice grievances without discrimination or reprisal.
Failure to Administer Ordered Oxygen to Resident
Penalty
Summary
The facility failed to administer the ordered oxygen to a resident (R2) who was complaining of shortness of breath. R2, who had multiple diagnoses including heart failure and chronic atrial fibrillation, reported feeling short of breath on the evening of 4/16/2024. Despite R2's repeated requests for oxygen, the Agency Registered Nurse (V16) on duty did not administer it, citing a lack of an order. R2 continued to feel unwell throughout the night and contacted her daughter for help the following morning. The next shift nurse (V10) administered the oxygen and R2 was subsequently transferred to the hospital for further treatment. Interviews with staff revealed that R2 had a standing order for oxygen as needed, which was not followed by V16. The Director of Nursing (V2) stated that nurses are expected to assess residents when needed, but there was no documentation showing that R2 was assessed for shortness of breath or that her oxygen saturation levels were checked during the night. R2's care plan included interventions for respiratory issues, but these were not implemented by V16, leading to a delay in necessary treatment.
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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 Elmhurst
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Place Christian Community | 0.8 mi | ★★★★★ | 0 | 0 |
| Alta Rehab At Oak Brook | 1.4 mi | ★★★★★ | 6 | 0 |
| Pearl Of Hillside,the | 3 mi | ★★★★★ | 8 | 0 |
| Aperion Care Westchester | 3.2 mi | ★★★★★ | 4 | 0 |
| Aperion Care Hillside | 3.2 mi | — | 0 | 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.