8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Lombard, IL
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
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
Staffing
RN hours / resident day
1.94
Registered nurse staffing
LPN hours / resident day
0.05
Licensed practical nurse staffing
Aide hours / resident day
2.68
Nurse aide staffing
Weekend hours
3.82
Weekend nurse staffing
RN turnover
38%
Annual RN turnover
Total nurse turnover
43%
Annual nurse turnover
Quality measures
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
Survey summary
Top issue: Quality of Life and Care (3 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Infection Control (3 deficiencies)
17 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
10 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Fire safety
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-08-01
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-01
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-07-16
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-08-01
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-08-01
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-01
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2025-08-01
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-08-01
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
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-08-01
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-07-16
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-08-01
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-08-01
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-07-04
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-07-04
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-07-04
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2024-07-04
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-07-04
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2024-07-04
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-07-04
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-01
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-07-01
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
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-03
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-07-08
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2024-07-03
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
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-07-08
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-08
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-07-03
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-09-21
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-09-22
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-09-22
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-09-22
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-09-22
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-09-22
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-09-01
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
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-09-01
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-01
Inspection history
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
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-26
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
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-22
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-22
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
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-14
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
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-04
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
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-04
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-07-04
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
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
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-07-04
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
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-07-04
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-08
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-16
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
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-09-22
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
Fine · fine $11,190
Fine
Fine · fine $18,996
Fine
5% Or Greater Direct Ownership Interest · Organization
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Operational/Managerial Control · Organization
Corporate Officer · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
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