Cycle 1
Health 2025-07-03 · Fire 2025-07-03
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Lombard, IL
Beacon Hill
3-star overall rating with 3-star inspections with $30,186 in total fines with 8 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
2400 South Finley Road, Lombard, IL
(630) 620-5850
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
45
Certified beds
Average residents
37
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Lifespace Communities
Operator or chain grouping
Approved since
1985-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
16 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.94
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.05
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.68
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.67
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.99
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.82
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
1.44
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.24
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.78
CMS adjusted RN staffing hours
Adjusted total hours
4.30
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,406
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.11
Composite VBP score used to determine payment impact.
Payment multiplier
0.9930
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.95% · Performance 25.54% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.80
Baseline 5.20% · Performance 6.70% · Measure score 3.80 · Achievement 3.80 · Improvement 0
Total nurse turnover
8.15
Baseline 48.15% · Performance 30.36% · Measure score 8.15 · Achievement 8.15 · Improvement 7.14
Adjusted total nurse staffing
4.10
Performance 4.24 hours · Measure score 4.10 · Achievement 4.10 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.02% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 322 · Observed rate 9.94% · Lower 95% interval 7.98% |
| Discharge to community | 55.13% |
50.57%
4.6 pts better
|
No Different than the National Rate · Eligible stays 323 · Observed rate 51.39% · Lower 95% interval 49.68% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 285 · Denominator 285 |
| Falls with major injury | 0.35% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 285 |
| Discharge self-care score | 46.74% |
53.69%
6.9 pts worse
|
Numerator 86 · Denominator 184 |
| Discharge mobility score | 40.22% |
50.94%
10.7 pts worse
|
Numerator 74 · Denominator 184 |
| Pressure ulcers or injuries, new or worsened | 1.4% |
2.29%
0.9 pts better
|
Numerator 4 · Denominator 285 · Adjusted rate 1.49% |
| Healthcare-associated infections requiring hospitalization | 6.7% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 259 · Observed rate 5.79% · Lower 95% interval 4.56% |
| Staff COVID-19 vaccination coverage | 1.33% |
8.2%
6.9 pts worse
|
Numerator 2 · Denominator 150 |
| Staff flu vaccination coverage | 93.6% |
42%
51.6 pts better
|
Numerator 161 · Denominator 172 |
| Discharge function score | 41.3% |
56.45%
15.2 pts worse
|
Numerator 76 · Denominator 184 |
| Transfer of health information to provider | 98.08% |
95.95%
2.1 pts better
|
Numerator 102 · Denominator 104 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 155 · Denominator 155 |
| Resident COVID-19 vaccinations up to date | 39.55% |
25.2%
14.3 pts better
|
Numerator 53 · Denominator 134 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.0% |
89.6%
0.4 pts better
|
93.4%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 90.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 10.0% |
3.3%
6.7 pts worse
|
3.3%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 68.5% |
68.8%
0.3 pts worse
|
81.7%
13.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 54.4% · Q2 64.7% · Q3 80.3% · Q4 73.8% · 4Q avg 68.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.6% |
14.0%
0.4 pts better
|
12.0%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.6% · Observed 12.8% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
2.3%
1.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 57.7% |
63.0%
5.3 pts worse
|
79.7%
22 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 57.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.0% |
26.2%
2.8 pts worse
|
23.9%
5.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.0% · Observed 26.0% · Expected 21.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-12 · Fire 2024-06-12
9 health deficiencies
Top issue: Infection Control (3 deficiencies)
17 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Cycle 3
Health 2023-08-10 · Fire 2023-08-10
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
10 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-07-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-07-03
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-07-16
F · Potential for more than minimal harm
2025-07-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-07-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-07-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-01
E · Potential for more than minimal harm
2025-07-03
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2025-08-01
E · Potential for more than minimal harm
2025-07-03
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-08-01
E · Potential for more than minimal harm
2025-07-03
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-08-01
E · Potential for more than minimal harm
2025-07-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-08-01
E · Potential for more than minimal harm
2025-07-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-07-16
E · Potential for more than minimal harm
2025-07-03
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-08-01
E · Potential for more than minimal harm
2025-07-03
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-08-01
F · Potential for more than minimal harm
2024-06-12
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-07-04
F · Potential for more than minimal harm
2024-06-12
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-07-04
F · Potential for more than minimal harm
2024-06-12
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-07-04
F · Potential for more than minimal harm
2024-06-12
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2024-07-04
F · Potential for more than minimal harm
2024-06-12
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-07-04
F · Potential for more than minimal harm
2024-06-12
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2024-07-04
F · Potential for more than minimal harm
2024-06-12
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-07-04
F · Potential for more than minimal harm
2024-06-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-01
F · Potential for more than minimal harm
2024-06-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-07-01
F · Potential for more than minimal harm
2024-06-12
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-07-01
F · Potential for more than minimal harm
2024-06-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-03
F · Potential for more than minimal harm
2024-06-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-07-08
E · Potential for more than minimal harm
2024-06-12
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2024-07-03
E · Potential for more than minimal harm
2024-06-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-07-03
E · Potential for more than minimal harm
2024-06-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-07-08
E · Potential for more than minimal harm
2024-06-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-08
E · Potential for more than minimal harm
2024-06-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-07-03
F · Potential for more than minimal harm
2023-08-10
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-09-21
F · Potential for more than minimal harm
2023-08-10
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-09-22
F · Potential for more than minimal harm
2023-08-10
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-09-22
F · Potential for more than minimal harm
2023-08-10
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-09-22
F · Potential for more than minimal harm
2023-08-10
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-09-22
F · Potential for more than minimal harm
2023-08-10
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-09-22
E · Potential for more than minimal harm
2023-08-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-09-01
E · Potential for more than minimal harm
2023-08-10
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-09-01
E · Potential for more than minimal harm
2023-08-10
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-09-01
E · Potential for more than minimal harm
2023-08-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-14
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-07-26
D · Potential for more than minimal harm
2025-07-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-26
F · Potential for more than minimal harm
2025-07-03
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-07-22
F · Potential for more than minimal harm
2025-07-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-22
D · Potential for more than minimal harm
2025-07-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-22
D · Potential for more than minimal harm
2025-06-26
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-07-08
G · Actual harm
2025-04-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-04
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-03-10
G · Actual harm
2024-06-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-04
F · Potential for more than minimal harm
2024-06-12
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2024-07-04
F · Potential for more than minimal harm
2024-06-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-04
D · Potential for more than minimal harm
2024-06-12
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-07-04
D · Potential for more than minimal harm
2024-06-12
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-07-04
D · Potential for more than minimal harm
2024-06-12
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-07-04
D · Potential for more than minimal harm
2024-06-12
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-07-04
D · Potential for more than minimal harm
2024-06-12
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-07-04
B · Minimal harm
2024-06-12
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-07-04
D · Potential for more than minimal harm
2024-02-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-08
G · Actual harm
2023-12-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-16
E · Potential for more than minimal harm
2023-08-10
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-10
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-08-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-15
Penalties and ownership
What sits behind the stars
$11,190
2025-04-02
Fine
Fine · fine $11,190
Fine
$18,996
2024-06-12
Fine
Fine · fine $18,996
Fine
Ownership
Lifespace Communities Inc
5% Or Greater Direct Ownership Interest · Organization
Blackford, Gary
Corporate Director · Individual
Collier, Scott
Corporate Director · Individual
Darkey-Hrinya, Joyce
Corporate Director · Individual
Delvaux, Susan
Corporate Director · Individual
Dutra, Ana
Corporate Director · Individual
Fields, Venita
Corporate Director · Individual
Gorman, Joseph
Corporate Officer · Individual
Hamm, Sara
Corporate Officer · Individual
Harshfield, Nicholas
Corporate Officer · Individual
Jantzen, Jesse
Corporate Officer · Individual
Kresse, Nikki
Corporate Officer · Individual
Lifespace Communities Inc
Operational/Managerial Control · Organization
Poinsette, Kenneth
Corporate Officer · Individual
Pope, Erin
Corporate Officer · Individual
Rosado, Albert
W-2 Managing Employee · Individual
Sokeye, Jonathan
Corporate Director · Individual
Spangler, Patrick
Corporate Director · Individual
Williams, David
Corporate Director · Individual
Yanofsky, Neal
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Bella Terra Lombard
Lombard, IL
3-star overall rating with 3-star inspections with 13 recent health deficiencies
#2
The Pearl Of Downers Grove
Downers Grove, IL
1-star overall rating with 1-star inspections with $30,264 in total fines with 20 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Alta Rehab At Oak Brook
Oak Brook, IL
2-star overall rating with 2-star inspections with $48,604 in total fines with 18 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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