Cycle 1
Health 2024-03-14 · Fire 2024-03-14
8 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Elmhurst, IL
Bella Terra Elmhurst
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
420 West Butterfield Road, Elmhurst, IL
(630) 832-2300
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
142
Certified beds
Average residents
104
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Legacy Healthcare
Operator or chain grouping
Approved since
1992-01-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
90 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 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
0.99
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.01
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.86
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.92
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.97
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.74
CMS adjusted RN staffing hours
Adjusted total hours
3.02
CMS adjusted total nurse staffing hours
Case-mix index
1.82
Higher values indicate more complex resident acuity
RN turnover
58%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,332
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.84
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.01% · Performance 27.42% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.27% · Performance 7.83% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.97
Performance 47.46% · Measure score 3.97 · Achievement 3.97 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.17
Baseline 2.47 hours · Performance 3.02 hours · Measure score 1.17 · Achievement 0 · Improvement 1.17
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.17% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 406 · Observed rate 9.61% · Lower 95% interval 8.12% |
| Discharge to community | 57.21% |
50.57%
6.6 pts better
|
Better than the National Rate · Eligible stays 424 · Observed rate 51.18% · Lower 95% interval 51.66% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.66% |
95.27%
3.4 pts better
|
Numerator 294 · Denominator 298 |
| Falls with major injury | 0.67% |
0.77%
0.1 pts better
|
Numerator 2 · Denominator 298 |
| Discharge self-care score | 49.32% |
53.69%
4.4 pts worse
|
Numerator 73 · Denominator 148 |
| Discharge mobility score | 51.35% |
50.94%
0.4 pts better
|
Numerator 76 · Denominator 148 |
| Pressure ulcers or injuries, new or worsened | 4.03% |
2.29%
1.7 pts worse
|
Numerator 12 · Denominator 298 · Adjusted rate 3.33% |
| Healthcare-associated infections requiring hospitalization | 7.83% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 281 · Observed rate 8.19% · Lower 95% interval 5.6% |
| Staff COVID-19 vaccination coverage | 3.88% |
8.2%
4.3 pts worse
|
Numerator 4 · Denominator 103 |
| Staff flu vaccination coverage | 96.33% |
42%
54.3 pts better
|
Numerator 105 · Denominator 109 |
| Discharge function score | 48.65% |
56.45%
7.8 pts worse
|
Numerator 72 · Denominator 148 |
| Transfer of health information to provider | 95.81% |
95.95%
0.1 pts worse
|
Numerator 183 · Denominator 191 |
| Transfer of health information to patient | 98.46% |
96.28%
2.2 pts better
|
Numerator 64 · Denominator 65 |
| Resident COVID-19 vaccinations up to date | 24.34% |
25.2%
0.9 pts worse
|
Numerator 37 · Denominator 152 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.0
0.2 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 3.3 · Expected 2.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
2.3
0.1 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.9 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
89.6%
6.1 pts better
|
93.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.1% · Q2 98.1% · Q3 98.0% · Q4 93.9% · 4Q avg 95.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.8% |
91.6%
2.2 pts better
|
95.5%
1.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
3.3%
0.5 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 3.8% · Q3 4.0% · Q4 2.0% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 87.6% |
50.3%
37.3 pts worse
|
11.4%
76.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 92.2% · Q2 87.2% · Q3 83.7% · Q4 87.2% · 4Q avg 87.6% |
| Percentage of long-stay residents who lose too much weight | 10.6% |
6.5%
4.1 pts worse
|
5.4%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 20.8% · Q3 11.1% · Q4 2.3% · 4Q avg 10.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.3% |
18.5%
8.2 pts better
|
19.6%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 10.0% · Q3 11.1% · Q4 10.9% · 4Q avg 10.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.3% |
22.8%
13.5 pts better
|
16.7%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 7.5% · Q3 7.5% · Q4 10.5% · 4Q avg 9.3% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.2% |
17.2%
1 pts better
|
16.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.7% |
15.0%
2.7 pts worse
|
14.9%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 15.2% · Q3 11.9% · Q4 23.3% · 4Q avg 17.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
1.1%
0.3 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
1.7%
0.7 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 0.0% · Q4 2.2% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.8% |
21.3%
1.5 pts worse
|
19.8%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.6% · Q2 23.4% · Q3 22.8% · Q4 21.3% · 4Q avg 22.8% |
| Percentage of long-stay residents with pressure ulcers | 10.8% |
5.2%
5.6 pts worse
|
5.1%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 14.7% · Q3 9.9% · Q4 4.7% · 4Q avg 10.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 66.0% |
68.8%
2.8 pts worse
|
81.7%
15.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 69.3% · Q2 73.6% · Q3 62.5% · Q4 60.5% · 4Q avg 66.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.6% |
14.0%
4.6 pts worse
|
12.0%
6.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.6% · Observed 17.7% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
2.3%
0.5 pts better
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.9% · Q3 1.5% · Q4 0.7% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 65.7% |
63.0%
2.7 pts better
|
79.7%
14 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 65.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.3% |
26.2%
1.1 pts worse
|
23.9%
3.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.3% · Observed 27.3% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-09 · Fire 2023-06-09
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-05-05 · Fire 2022-05-05
14 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-03-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-12
F · Potential for more than minimal harm
2024-03-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-03-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-03-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-03-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-04-12
F · Potential for more than minimal harm
2023-06-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-19
F · Potential for more than minimal harm
2023-06-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-07-06
F · Potential for more than minimal harm
2023-06-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-06
F · Potential for more than minimal harm
2023-06-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-06-09
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-06-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-06-09
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-06-09
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-06-09
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2023-07-06
F · Potential for more than minimal harm
2022-05-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-05-27
E · Potential for more than minimal harm
2022-05-05
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 2022-05-27
E · Potential for more than minimal harm
2022-05-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-05-27
E · Potential for more than minimal harm
2022-05-05
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-05-27
E · Potential for more than minimal harm
2022-05-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-05-27
E · Potential for more than minimal harm
2022-05-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-05-27
C · Minimal harm
2022-05-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-05-27
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-04
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-09-05
G · Actual harm
2024-12-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-01
D · Potential for more than minimal harm
2024-12-30
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 2025-01-01
D · Potential for more than minimal harm
2024-04-25
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 2024-04-26
D · Potential for more than minimal harm
2024-04-25
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-04-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-26
E · Potential for more than minimal harm
2024-03-14
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-03-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-03-14
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 2024-03-15
D · Potential for more than minimal harm
2024-03-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-03-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-03-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-03-14
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-03-15
E · Potential for more than minimal harm
2023-12-28
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 2023-12-29
D · Potential for more than minimal harm
2023-12-28
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 2023-12-29
D · Potential for more than minimal harm
2023-12-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-09-22
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2023-10-04
E · Potential for more than minimal harm
2023-06-09
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-06-10
E · Potential for more than minimal harm
2023-06-09
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-06-10
E · Potential for more than minimal harm
2023-06-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-10
G · Actual harm
2023-03-06
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 2023-03-25
F · Potential for more than minimal harm
2022-05-05
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-05-27
E · Potential for more than minimal harm
2022-05-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-05-27
E · Potential for more than minimal harm
2022-05-05
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-05-27
E · Potential for more than minimal harm
2022-05-05
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-05-27
E · Potential for more than minimal harm
2022-05-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-05-05
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 2022-05-27
D · Potential for more than minimal harm
2022-05-05
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 2022-05-27
D · Potential for more than minimal harm
2022-05-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-05-05
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-05-27
Penalties and ownership
What sits behind the stars
Ownership
Ninio, Mordechay
5% Or Greater Direct Ownership Interest · Individual
Chaim Rajchenbach Descendants Tr Ua 04282008
5% Or Greater Direct Ownership Interest · Organization
Doros Generation Trust U/A/D 1/3/12
5% Or Greater Direct Ownership Interest · Organization
Garden, Daniel
5% Or Greater Direct Ownership Interest · Individual
Brown, Tremaine
W-2 Managing Employee · Individual
Tbdmd Il, LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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Park Place Christian Community
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5-star overall rating with 4-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
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
#3
Pearl Of Hillside,the
Hillside, IL
2-star overall rating with 3-star inspections with $38,990 in total fines with 17 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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