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 Lombard during CMS and state inspections, most recent first.
A resident was admitted with multiple pressure-related skin injuries, including deep tissue injuries and unstageable pressure ulcers to the sacral and bilateral buttock areas, and had a care plan directing staff to monitor and document the location, size, and treatment of these wounds. The wound nurse completed an admission skin/wound evaluation but did not obtain or document measurements of the bilateral buttock pressure injuries, stating she sometimes avoids measuring when unsure how to do so or concerned about overestimating size, and may wait for the wound NP. The DON reported that pressure injuries should be measured at assessment and acknowledged that without initial measurements it is not possible to determine changes in wound size. This practice did not comply with the facility’s Wound Care Guidelines, which require wound assessments to include wound type, etiology, location, stage, and measurements of length, width, and depth, among other elements.
A resident with impaired mobility, pain, and multiple chronic conditions, including pressure ulcers, required staff assistance with transfers. After a shower and transfer back to bed by a CNA, redness and later a skin tear were noted on the resident’s left lower leg. The CNA’s inspection revealed that square sections in the middle of the bed frame were missing plastic protective covers, leaving exposed metal. The resident’s daughter reported that the resident had scratched her leg on the bed due to these missing pieces, and facility staff, including maintenance and administration, confirmed that the bed frame lacked required plastic protective components needed for safe use.
A resident with cognitive impairment and recent surgery alleged that a CNA held her wrist during care and did not release it when asked, causing discomfort. The allegation was reported to a nurse, who did not notify the abuse coordinator as required, leading to a delay in reporting to both facility leadership and authorities. Interviews confirmed the resident's complaints were not promptly reported by staff, contrary to facility policy.
The facility failed to provide timely incontinent care to two residents dependent on staff for toilet hygiene. One resident was found with a urine-soaked brief, while another was found with a urine and feces-soaked brief. Both residents' care plans required checks every two hours, which were not adhered to, leading to prolonged exposure to moisture.
A resident with severe cognitive impairment and a stage 4 sacral pressure ulcer did not receive wound care as per physician orders. The wound care nurse failed to irrigate the wound with normal saline and used hydrogel-moistened gauze instead of calcium alginate, despite recommendations from the wound care nurse practitioner. The nurse cited a lack of supplies as the reason for not following the prescribed treatment plan.
The facility failed to provide timely incontinent care to three residents dependent on assistance for toilet hygiene. One resident with mild cognitive impairment was found with a urine-soaked diaper hours after being changed, despite a care plan for two-hour checks. Another resident with similar impairment was also found with a soaked brief, and a third resident with severely impaired cognition was found with a double diaper soaked in urine. Staff acknowledged the requirement for two-hour checks, highlighting a failure to adhere to care plans and facility policy.
A resident's Norco medication was misappropriated in an LTC facility. The resident, with severe cognitive impairment, was prescribed Norco for pain management. During a shift change, it was discovered that the medication and narcotic count sheet were missing. An RN from agency staffing, who had access to the narcotic box, signed off on taking tablets at unusual times. Despite being the only one with access, the RN denied knowledge of the missing items. The incident was reported to authorities.
The facility failed to sanitize food preparation equipment before use, potentially affecting 138 residents. A chef used a rag with only soap and water to wash food processor components and a spatula, which were not sanitized or air-dried before preparing pureed meals. The Food Service Director confirmed the need for proper sanitization procedures.
The facility failed to assess and notify the wound nurse practitioner of a new wound for a high-risk resident, leading to its deterioration into a stage 2 to 3 pressure ulcer. Additionally, several residents at risk for pressure ulcers did not receive proper pressure-relieving interventions, such as heel elevation, as outlined in their care plans. These deficiencies highlight lapses in following the facility's Wound Care Guidelines Policy.
The facility failed to consistently provide and document restorative services, including ROM exercises and splint applications, for several residents. A resident with declining mobility did not receive prescribed exercises, while another resident with hemiplegia reported missing daily ROM sessions. Additionally, a resident with contractures had incomplete documentation for ROM and splint application, indicating a lack of adherence to care plans.
A resident with multiple sclerosis, who is incontinent, experienced a two-hour delay in receiving assistance after soiling himself, despite being alert and oriented. His care plan required staff checks every two hours, but there was no documentation on the day of the incident. The facility's policy mandates respect for residents' privacy and dignity, which was not upheld.
The facility failed to maintain fall interventions for two residents with a history of falls. One resident's bed was not consistently in the lowest position, and the call light was often out of reach, despite previous fall-related injuries. Another resident's bed alarm was improperly set up, with the sensor pad unplugged and not under the resident, contrary to the care plan. The facility's guidelines required safety interventions for at-risk residents.
The facility failed to properly store nebulizer equipment for three residents, leading to potential cross-contamination. Observations showed nebulizer masks and tubing stored in open plastic bags with outdated dates or touching surfaces, contrary to facility policy requiring weekly changes and proper storage. A nurse confirmed the need for dated and bagged storage to prevent contamination.
A resident's morphine prescription was not reordered due to a pharmacy requirement for an actual signature, resulting in only 6 tablets being sent instead of the prescribed 60. The resident's MAR showed the medication was unavailable for two days, during which oxycodone was administered for pain management. The DON explained the issue with the electronic signature, and the NP confirmed the prescription could have been refilled over the weekend.
The facility failed to ensure staff wore appropriate PPE for two residents on enhanced barrier precautions (EBP). A CNA provided care to a resident with a gastrostomy tube and another with a Foley catheter and surgical wound without donning a gown, despite the care plans and facility policy requiring gowns and gloves during high-contact activities. The infection preventionist confirmed the need for both gloves and gowns, highlighting a deficiency in infection control practices.
The facility failed to provide timely incontinent care to four dependent residents, as observed in multiple instances where residents were found with soaked briefs despite care plans requiring checks every two hours. The DON confirmed that staff are supposed to check and offer incontinent care every two hours, but this policy was not followed.
A resident with significant medical conditions reported not being changed by agency staff during a night shift, resulting in him being found soaked with urine and stool the next morning. Interviews with CNAs and the ADON confirmed the resident's account and highlighted issues with agency staff adherence to the facility's incontinence care policy.
Failure to Measure and Document Pressure Injury Size on Admission
Penalty
Summary
The deficiency involves the facility’s failure to follow its wound care policy requiring complete pressure injury assessments, including measurements, for a resident admitted with multiple pressure-related skin injuries. The resident’s EMR showed admission with diagnoses including rheumatoid arthritis, chronic kidney disease, congestive heart failure, pressure-induced deep tissue damage of the right buttock, and unstageable pressure ulcers of the sacral region and left buttock. The resident’s skin integrity care plan documented actual skin impairment related to sacral and bilateral buttock unstageable pressure ulcers and included an intervention to monitor and document the location, size, and treatment of skin injuries. Despite this, the admission/readmission nursing assessment and a Skin/Wound Evaluation completed within 24 hours of admission did not include measurements of the bilateral buttock pressure injuries. During interview, the wound nurse stated she assesses newly admitted residents for skin impairments within 24 hours of admission but acknowledged she did not measure this resident’s buttock pressure injuries and was unsure why. She further stated that sometimes she does not measure pressure injuries if she is unsure how to measure them or is concerned about measuring them as larger than they are, and may wait for the wound nurse practitioner to assess. The DON stated that the admitting nurse assesses and documents wounds and that the wound nurse then assesses within 24 hours, and she believed pressure injuries should be measured at the time of assessment. The DON also stated that without admission wound measurements, she could not determine if a wound had enlarged between admission and the wound nurse practitioner’s visit. The facility’s Wound Care Guidelines policy required wound assessment documentation to include, at a minimum, wound type, etiology, location, date, stage, and measurements (length, width, depth), along with wound bed, edges, exudate, undermining, tunneling, and wound-related pain, which was not followed for this resident’s bilateral buttock pressure injuries.
Failure to Maintain Bed Hardware Safely, Resulting in Resident Skin Tear
Penalty
Summary
The facility failed to ensure a resident’s bed was free from accident hazards when a bed was used without required plastic protective pieces on the metal frame. The resident involved had multiple diagnoses, including rheumatoid arthritis, chronic kidney disease, congestive heart failure, and several pressure ulcers, and had an ADL care plan indicating impaired mobility, pain, and a need for staff assistance with transfers. After providing a shower, a CNA transferred the resident back to bed and observed redness on the resident’s left lower leg. The CNA inspected both the shower chair and the bed and noted that square pieces in the middle of the bed frame were missing plastic protective covers. A subsequent Skin Alteration Nursing Evaluation documented a rear left lower leg skin tear for the resident later that same day. During a care plan meeting, the resident’s daughter reported that there were missing pieces on the bed and that the resident had scratched her leg on the bed. The Admissions Director acknowledged hearing from the Social Services Director that a resident’s bed needed to be replaced due to missing plastic protective pieces, and the Maintenance Assistant confirmed that two plastic protective pieces were missing from the center of the bed frame, leaving exposed metal squares. The Administrator stated that a resident’s bed should have all required pieces to ensure resident safety, confirming that the bed in use for this resident did not meet that standard at the time of the incident.
Failure to Promptly Report Allegation of Abuse
Penalty
Summary
Facility staff failed to promptly report a resident's allegation of abuse to the facility's abuse coordinator as required by facility policy. A resident with multiple medical conditions, including moderate cognitive impairment, blindness, and recent abdominal surgery, reported that during incontinence care, a CNA held her left wrist and would not let go when asked, causing her discomfort and prompting her to swat at the CNA. The resident recognized the CNA by her voice and reported the incident to her nurse the following morning, stating she felt rushed during care. The nurse who received the allegation did not report it directly to the abuse coordinator but instead relayed the information to her supervisor, the Assistant Director of Nursing (ADON). The ADON, in turn, discussed the matter with the Director of Nursing (DON) later in the day, after the resident's Power of Attorney also reported concerns. The Assistant Administrator only became aware of the allegation after the DON received a voicemail from the resident's Power of Attorney. The initial report to authorities and the start of the investigation were delayed until the Assistant Administrator interviewed the resident and determined an allegation of mental abuse had occurred. Interviews with the involved CNAs confirmed that the resident had complained of pain and asked for her wrist to be released during care, but the CNA continued to hold her wrist. Neither the CNA nor the assisting agency CNA reported the incident or the resident's complaints at the time. The facility's policy requires immediate reporting of all abuse allegations to the Administrator, but this protocol was not followed, resulting in a delay in both internal and external reporting of the suspected abuse.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care to two residents, R4 and R5, who were dependent on staff for toilet hygiene. R4, an elderly female with intact cognition, was admitted on a specific date and was observed at 10:10 AM with a urine-soaked incontinent brief that had brownish discoloration. R4 reported that she had been changed at 4:30 AM and was waiting to be changed again. The CNA responsible for R4 stated that she started her shift at 6:00 AM and was delayed in providing care due to passing breakfast trays. R4's care plan required staff to check for incontinence every two hours and as needed. R5, another elderly female with severely impaired cognition, was observed at 10:15 AM with a urine and feces-soaked brief, also with dark brown discoloration. A CNA, who was not assigned to R5, was checking on her and noted the condition. R5's care plan similarly required checks every two hours and as needed. The Director of Nursing confirmed that the facility's policy was to provide incontinent care every two hours and as needed, and noted that prolonged exposure to moisture could lead to Moisture Associated Skin Dermatitis (MASD). The facility's policy on incontinent and perineal care, revised previously, mandated rounds every two hours to check for incontinence.
Failure to Follow Wound Care Orders for Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to adhere to physician orders for wound care management of a stage 4 sacral pressure ulcer in a resident with severe cognitive impairment. The resident was admitted with an unstageable sacral wound and additional wounds on both heels and the right knee. Upon observation, the wound care nurse did not follow the prescribed treatment plan, which included irrigating the wound with normal saline and using calcium alginate for packing. Instead, the nurse used saline-sprayed gauze for cleansing and hydrogel-moistened gauze for packing, deviating from the physician's orders. The wound care nurse practitioner had recommended the use of calcium alginate due to the moderate to heavy drainage observed in the wound, but the nurse did not implement this recommendation. The nurse cited a lack of individual saline vials and Cavilon spray as reasons for not following the prescribed wound care protocol. The Director of Nursing confirmed that the nurse should have followed the wound care orders as documented. The wound care nurse practitioner also noted that they could not enter orders into the system due to being from an outside agency, and the nurse was responsible for entering the orders under the physician's name.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care to three residents who were dependent on assistance for activities of daily living, specifically toilet hygiene. Resident 2, a female with mild cognitive impairment, reported being changed at 5:00 AM and was found with a urine-soaked diaper at 10:05 AM, despite the care plan indicating checks every two hours. Similarly, Resident 3, also with mild cognitive impairment, was last changed at 4:30 AM and was found with a urine-soaked brief at 10:00 AM, with a care plan requiring checks every two hours. Resident 4, with severely impaired cognition, was found with a double diaper soaked in urine at 10:10 AM. The facility's policy, revised in June, mandates incontinent care rounds every two hours. Staff members acknowledged the requirement for two-hour checks and the need for more frequent care for residents on medications like Lasix or those who are heavy wetters. The observations and interviews indicate a failure to adhere to the established care plans and facility policy, resulting in inadequate care for the residents.
Misappropriation of Resident's Narcotic Medication
Penalty
Summary
The facility failed to protect a resident from the misappropriation of prescribed narcotic medication, specifically Norco 5/325 mg. The resident, who has a history of dementia, alcohol dependence, bipolar disorder, and other medical conditions, was prescribed Norco for pain management. The medication was to be administered every six hours as needed. However, discrepancies were noted in the narcotic count sheet, indicating that more tablets were signed out than were actually administered to the resident. The incident was identified during a shift change narcotic count when it was discovered that both the Norco tablets and the narcotic count sheet were missing. The LPN on duty reported that the RN from agency staffing, who was responsible for the medication during the previous shift, had signed off on taking three tablets at specific times, which was unusual given the resident's routine of receiving the medication only once daily. The RN was the only staff member with access to the narcotic box during her shift, raising suspicions about her involvement in the misappropriation. Interviews with the staff involved revealed that the RN denied knowledge of the missing medication and count sheet, despite being the only one with access. The Assistant Director of Nursing was notified, and attempts to contact the RN were initially unsuccessful. The facility's incident report documented the misappropriation and the involvement of the local police and public health authorities, but the focus of the deficiency was on the failure to safeguard the resident's medication from wrongful use.
Failure to Sanitize Food Preparation Equipment
Penalty
Summary
The facility failed to ensure that food preparation equipment was properly sanitized before preparing food, which could potentially affect all 138 residents receiving food from the kitchen. During an observation, the chef was seen using a rag from a bucket containing only water with soap to wash food preparation items, including a food processor container, lid, blade, and spatula. These items were not sanitized or air-dried before being used to prepare pureed meals for the residents. The Food Service Director confirmed that the items should have been brought to the dish room for proper washing, rinsing, sanitizing, and air drying. The chef continued to use the un-sanitized equipment to prepare pureed broccoli and pasta, which were then served to the residents. The facility's Diet Type Report indicated that only one resident was NPO and did not receive food from the kitchen, meaning the unsanitized food preparation could potentially impact the remaining residents.
Failure to Implement Pressure Ulcer Prevention and Assessment
Penalty
Summary
The facility failed to ensure proper assessment and notification regarding a new wound for a resident, R98, who was at high risk for pressure ulcers. Despite having a history of severe pressure ulcers, R98's new sacral wound was not reported to the wound nurse practitioner, V13, who was unaware of the wound until much later. The wound, initially a skin tear, was not properly documented or assessed from 6/7/24 to 6/25/24, leading to its deterioration into a stage 2 to 3 pressure ulcer. The facility's Director of Nursing, V2, expected staff to report new wounds and ensure timely assessments, which did not occur in this case. Additionally, the facility did not implement pressure-relieving interventions for several residents at risk for pressure ulcers. R240 was observed with heels flat on the bed despite having an unstageable pressure injury and instructions to float heels with foam boots. Similarly, R105 and R121 were found with their heels resting directly on the mattress, contrary to their care plans that required heel elevation or the use of heel protector boots. These lapses in following care plans and facility guidelines contributed to the risk of pressure ulcer development or worsening. The facility's Wound Care Guidelines Policy, which mandates the elevation of heels and timely wound assessments, was not adhered to for the residents reviewed. The lack of consistent implementation of pressure-relieving measures and failure to notify the wound nurse practitioner of new wounds led to deficiencies in the care provided to residents at risk for pressure injuries.
Inconsistent Restorative Services and Documentation
Penalty
Summary
The facility failed to provide appropriate restorative services to residents, as evidenced by the lack of consistent range of motion (ROM) exercises and splint applications for several residents. Resident R28, who was previously able to ambulate with assistance, reported a decline in mobility and stated that he did not receive the prescribed exercises, such as standing with a walker or using an arm bike. The task history confirmed that these exercises were infrequently documented, indicating they were not regularly performed. Resident R14, who was supposed to receive active and active-assisted ROM exercises twice daily, also experienced inconsistencies in the provision of these services. The documentation for R14 showed multiple days without any recorded restorative services, suggesting a failure to adhere to the prescribed regimen. Similarly, Resident R79, diagnosed with hemiplegia, reported not receiving daily passive ROM exercises as ordered, with documentation missing for several days. Resident R5, who had contractures and required daily passive ROM and splint application, was found to have incomplete documentation for these services. The restorative aides were responsible for providing ROM and applying splints, but the records showed numerous days where these tasks were not documented. Interviews with staff confirmed that the restorative services were not consistently provided or recorded, contributing to the deficiency in care.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to treat a resident, identified as R9, in a dignified manner. On the morning of June 23, 2024, R9 activated his call light at approximately 6:20 AM, seeking assistance after soiling himself with stool and urine. Despite being alert and oriented, as confirmed by a Registered Nurse (RN), R9 did not receive help until after 8:20 AM, resulting in a two-hour delay. R9's Minimum Data Set indicated a BIMs score of 14, confirming cognitive intactness. His care plan, dated June 7, 2024, specified that he is always incontinent of bladder and bowel due to multiple sclerosis, with an intervention for staff to check him every two hours. However, there was no documentation of bowel charting on June 23, 2024. The facility's Privacy and Dignity policy, dated June 6, 2024, mandates that residents' privacy and dignity be respected at all times, which was not adhered to in this instance.
Failure to Implement Fall Interventions for Residents
Penalty
Summary
The facility failed to ensure fall interventions were in place for two residents with a history of falls. For one resident, R108, observations revealed that the bed was not in the lowest position on multiple occasions, and the call light was either on the floor or not within reach. Despite the implementation of interventions such as a bed alarm, floor mats, and positioning the bed at the lowest level after a previous fall, these measures were not consistently maintained. The resident had previously fallen and sustained injuries, including a broken hip and leg. For another resident, R33, the bed alarm system was not properly set up. The sensor pad was found hanging behind the headboard and unplugged from the alarm box, contrary to the care plan that required a bed alarm to prevent falls. A Certified Nursing Assistant confirmed the improper setup of the bed alarm, which should have been placed under the resident and connected to the alarm box. The facility's Fall Prevention Program Guidelines emphasized the need for safety interventions for residents at risk of falls, including ensuring call devices are within reach and utilizing personal alarms when appropriate.
Improper Storage of Nebulizer Equipment
Penalty
Summary
The facility failed to ensure proper storage of nebulizer equipment to prevent cross-contamination for three residents. Observations revealed that one resident's nebulizer mask and tubing were stored in an open plastic bag dated over two months prior, indicating a lack of timely replacement. Another resident's nebulizer equipment was similarly stored in an open plastic bag with the same outdated date, and the resident confirmed occasional use of the nebulizer. A third resident's nebulizer mask was found touching a privacy curtain, without being stored in a plastic bag or dated, which further indicates improper storage practices. Interviews with a registered nurse confirmed that nebulizer tubing and masks should be dated and stored in plastic bags to prevent contamination, with orders typically requiring weekly changes. The facility's policy also mandates changing oxygen setups every seven days or as needed if heavily soiled. The failure to adhere to these protocols resulted in the improper storage and potential contamination of nebulizer equipment for the residents involved.
Failure to Reorder Resident's Morphine Prescription
Penalty
Summary
The facility failed to reorder a resident's medication, specifically morphine, which was necessary for pain management. The resident was observed waiting for the medication, and it was revealed that the pharmacy only sent 6 tablets instead of the prescribed 60 due to a requirement for an actual signature on the prescription. The Director of Nursing explained that the hospital's electronic signature was not sufficient for the pharmacy to fill the entire prescription. The resident's Medication Administration Record (MAR) indicated that the morphine was unavailable for two days, during which time the resident was given oxycodone for pain management. The Nurse Practitioner confirmed that the prescription could have been refilled over the weekend by a covering provider and eventually refilled the morphine prescription.
Inadequate PPE Use for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff wore appropriate personal protective equipment (PPE) when providing care to residents on enhanced barrier precautions (EBP). Specifically, two residents, one with a gastrostomy tube and another with an indwelling Foley catheter and a surgical wound, were not provided care with the required PPE. The care plans for both residents indicated that staff should use gowns and gloves during high-contact activities, such as dressing, bathing, and transferring. However, during observations, a certified nursing assistant (CNA) was seen providing incontinence care and repositioning one resident, and assisting another resident to a wheelchair, without donning a gown, although gloves were used. The facility's EBP policy, revised earlier in the month, mandates the use of gowns and gloves to reduce the transmission of resistant organisms during high-contact care activities for residents with medical devices or wounds. The infection preventionist confirmed that staff should wear both gloves and gowns when in contact with residents on EBP. Despite this policy, the CNA did not adhere to the guidelines, leading to a deficiency in infection control practices.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care to dependent residents, as observed in four out of five residents reviewed for activities of daily living (ADL) care. Resident 1, a female with severely impaired cognition, was found with a soaked inner liner inside an incontinent brief at 9:22 AM, despite being checked at 6:20 AM and found dry. Resident 3, also with severely impaired cognition, was observed with a urine-soaked inner pad at 9:35 AM, even though her care plan required checks every two hours. Resident 4, with intact cognition, was found in bed with a double-layered incontinent brief soaked with urine at 9:42 AM, having last been changed at around 5:50 AM. Resident 5, with intact cognition, reported receiving personal care last at midnight and was found with a heavily soaked, blackish-colored incontinent brief at 9:52 AM, with urine and stool smeared all over her buttocks. The facility's policy requires incontinent care rounds every two hours, which was not adhered to in these cases. The Director of Nursing (DON) confirmed that staff are supposed to check and offer incontinent care every two hours and as needed. The facility's revised Perineal Care policy, dated 7/28/23, also mandates rounds at least every two hours to check for incontinence. Despite these policies, the observations and interviews indicate a failure to provide timely incontinent care, leading to residents being left in soiled briefs for extended periods. This deficiency highlights a significant lapse in adhering to the care plans and facility policies designed to ensure the well-being and hygiene of dependent residents.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure a resident who is dependent on staff received assistance with incontinence care. The resident, a [AGE] year-old male with diagnoses including hemiplegia and hemiparesis following cerebral infarction, morbid obesity, generalized anxiety, and major depression disorder, reported that on a specific night shift, he was not changed by the agency CNA from 10 PM to 6 AM. The resident pressed his call light multiple times in the morning, but it was not until after 6:00 AM that the day shift CNA responded and found him soaked with urine and stool, indicating he had not been changed since the night before around 8:30 PM. The resident's care plan requires staff to check for incontinence episodes every two hours, which was not adhered to by the agency staff on that night shift. Interviews with the facility's CNAs and the Assistant Director of Nursing (ADON) corroborated the resident's account. The day shift CNA confirmed finding the resident soaked and having to change the complete bed due to the extent of soiling. Another CNA mentioned that it was not uncommon to find residents not changed by agency staff when she started her morning shift. The ADON acknowledged that the resident had previously reported similar issues with agency staff and that the facility tries to assign regular staff to him due to his dissatisfaction with agency staff. The facility's policy mandates rounds at least every two hours to check for incontinence, which was not followed in this instance.
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 1,801 citations issued within 25 miles in the last 12 months — including the 29 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 Lombard
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beacon Hill | 0.4 mi | ★★★★★ | 0 | 0 |
| The Pearl Of Downers Grove | 1.6 mi | ★★★★★ | 3 | 0 |
| Alta Rehab At Oak Brook | 2.8 mi | ★★★★★ | 6 | 0 |
| Bella Terra Elmhurst | 3.9 mi | ★★★★★ | 1 | 0 |
| Oakwood Rehab And Nursing Center | 4.2 mi | ★★★★★ | 14 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Bella Terra Lombard.
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 July 2026) and official state health department websites.