Lombard, IL

Bella Terra Lombard

3-star overall rating with 3-star inspections with 13 recent health deficiencies

2100 South Finley Road, Lombard, IL

(630) 495-4000

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

224

Certified beds

Average residents

151

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Legacy Healthcare

Operator or chain grouping

Approved since

1985-10-01

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

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

0.94

Registered nurse staffing · state 0.73 · national 0.68

LPN hours / resident day

0.46

Licensed practical nurse staffing · state 0.64 · national 0.87

Aide hours / resident day

1.94

Nurse aide staffing · state 2.13 · national 2.35

Total nurse hours

3.33

All reported nurse hours · state 3.49 · national 3.89

Licensed hours

1.40

RN + LPN hours · state 1.36 · national 1.54

Weekend hours

3.14

Weekend nurse staffing · state 3.09 · national 3.43

Weekend RN hours

0.90

Weekend registered nurse coverage · state 0.56 · national 0.47

Physical therapist

0.02

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.72

CMS adjusted RN staffing hours

Adjusted total hours

2.55

CMS adjusted total nurse staffing hours

Case-mix index

1.79

Higher values indicate more complex resident acuity

RN turnover

36%

Annual RN turnover · state 44% · national 45%

Total nurse turnover

46%

Annual nurse turnover · state 46% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,344

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

20.71

Composite VBP score used to determine payment impact.

Payment multiplier

0.9824

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

2.14

Baseline 19.36% · Performance 20.44% · Measure score 2.14 · Achievement 2.14 · Improvement 0

Healthcare-associated infections

1.96

Baseline 5.29% · Performance 7.25% · Measure score 1.96 · Achievement 1.96 · Improvement 0

Total nurse turnover

4.19

Baseline 41.24% · Performance 46.55% · Measure score 4.19 · Achievement 4.19 · Improvement 0

Adjusted total nurse staffing

Baseline 2.65 hours · Performance 2.61 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.37%	10.72% 0.6 pts worse	No Different than the National Rate · Eligible stays 212 · Observed rate 13.21% · Lower 95% interval 8.18%
Discharge to community	59.64%	50.57% 9.1 pts better	Better than the National Rate · Eligible stays 183 · Observed rate 51.37% · Lower 95% interval 50.81%
Medicare spending per beneficiary	1.2	1.02 0.2 pts worse
Drug regimen review with follow-up	99.35%	95.27% 4.1 pts better	Numerator 152 · Denominator 153
Falls with major injury	0.65%	0.77% 0.1 pts better	Numerator 1 · Denominator 153
Discharge self-care score	67.68%	53.69% 14 pts better	Numerator 67 · Denominator 99
Discharge mobility score	62.63%	50.94% 11.7 pts better	Numerator 62 · Denominator 99
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 153 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	7.25%	7.12% 0.1 pts worse	No Different than the National Rate · Eligible stays 124 · Observed rate 8.87% · Lower 95% interval 5.14%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 115
Staff flu vaccination coverage	73.98%	42% 32 pts better	Numerator 91 · Denominator 123
Discharge function score	69.7%	56.45% 13.2 pts better	Numerator 69 · Denominator 99
Transfer of health information to provider	95.45%	95.95% 0.5 pts worse	Numerator 42 · Denominator 44
Transfer of health information to patient	97.56%	96.28% 1.3 pts better	Numerator 80 · Denominator 82
Resident COVID-19 vaccinations up to date	71.11%	25.2% 45.9 pts better	Numerator 64 · Denominator 90

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.6	2.0 0.6 pts worse	1.9 0.7 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.8 · Expected 2.0 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.7	2.3 0.6 pts better	1.8 0.1 pts better	Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.6 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	97.3%	89.6% 7.7 pts better	93.4% 3.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.8% · Q3 95.1% · Q4 97.5% · 4Q avg 97.3%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	94.0%	91.6% 2.4 pts better	95.5% 1.5 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 94.0%
Percentage of long-stay residents experiencing one or more falls with major injury	2.0%	3.3% 1.3 pts better	3.3% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.4% · Q3 1.6% · Q4 0.8% · 4Q avg 2.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	99.3%	50.3% 49 pts worse	11.4% 87.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.3% · Q3 100.0% · Q4 99.1% · 4Q avg 99.3%
Percentage of long-stay residents who lose too much weight	10.1%	6.5% 3.6 pts worse	5.4% 4.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 13.0% · Q3 9.9% · Q4 6.7% · 4Q avg 10.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	22.4%	18.5% 3.9 pts worse	19.6% 2.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 24.8% · Q2 23.9% · Q3 20.7% · Q4 20.0% · 4Q avg 22.4%
Percentage of long-stay residents who received an antipsychotic medication	15.2%	22.8% 7.6 pts better	16.7% 1.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 15.4% · Q3 16.9% · Q4 13.6% · 4Q avg 15.2% · 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	15.8%	17.2% 1.4 pts better	16.3% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 21.0% · Q3 13.2% · Q4 13.5% · 4Q avg 15.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	12.4%	15.0% 2.6 pts better	14.9% 2.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 20.0% · Q3 7.8% · Q4 12.5% · 4Q avg 12.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.3%	1.1% 0.8 pts better	1.0% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.4%	1.7% 0.3 pts better	1.7% 0.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.8% · Q3 0.0% · Q4 0.8% · 4Q avg 1.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	11.9%	21.3% 9.4 pts better	19.8% 7.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.4% · Q2 10.4% · Q3 10.0% · Q4 13.0% · 4Q avg 11.9%
Percentage of long-stay residents with pressure ulcers	2.2%	5.2% 3 pts better	5.1% 2.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.5% · Q3 3.4% · Q4 2.6% · 4Q avg 2.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	77.8%	68.8% 9 pts better	81.7% 3.9 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 68.2% · Q2 72.6% · Q3 85.4% · Q4 85.4% · 4Q avg 77.8%
Percentage of short-stay residents who had an outpatient emergency department visit	16.6%	14.0% 2.6 pts worse	12.0% 4.6 pts worse	Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 17.2% · Expected 11.6% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.5%	2.3% 0.2 pts worse	1.6% 0.9 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.8% · Q3 2.5% · Q4 1.9% · 4Q avg 2.5% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	58.4%	63.0% 4.6 pts worse	79.7% 21.3 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 58.4%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	19.7%	26.2% 6.5 pts better	23.9% 4.2 pts better	Short Stay · 20240701-20250630 · Adjusted 19.7% · Observed 23.3% · Expected 28.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-06-26 · Fire 2024-06-26

13 health deficiencies

Top issue: Quality of Life and Care (8 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2023-07-21 · Fire 2023-07-21

11 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

1 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Cycle 3 Health 2022-04-28 · Fire 2022-04-28

14 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2023-07-21

E26 · Emergency Preparedness Deficiencies

Fire Safety

Establish roles under a Waiver declared by secretary.

Corrected 2023-08-30

Inspection history

Recent health citations

D · Potential for more than minimal harm 2026-01-28

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2026-02-06

D · Potential for more than minimal harm 2026-01-28

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 2026-02-06

D · Potential for more than minimal harm 2025-10-06

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-11-14

D · Potential for more than minimal harm 2025-03-11

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 2025-03-21

D · Potential for more than minimal harm 2025-03-11

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-03-21

D · Potential for more than minimal harm 2024-07-20

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 2024-07-26

D · Potential for more than minimal harm 2024-07-17

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2024-07-24

F · Potential for more than minimal harm 2024-06-26

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-07-05

E · Potential for more than minimal harm 2024-06-26

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-07-05

E · Potential for more than minimal harm 2024-06-26

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2024-07-05

D · Potential for more than minimal harm 2024-06-26

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 2024-07-05

D · Potential for more than minimal harm 2024-06-26

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 2024-07-05

D · Potential for more than minimal harm 2024-06-26

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-07-05

D · Potential for more than minimal harm 2024-06-26

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 2024-07-05

D · Potential for more than minimal harm 2024-06-26

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-07-05

E · Potential for more than minimal harm 2024-04-11

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 2024-04-12

D · Potential for more than minimal harm 2024-04-02

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 2024-04-03

D · Potential for more than minimal harm 2024-02-21

F622 · Resident Rights Deficiencies

Health

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Corrected 2024-03-21

G · Actual harm 2023-08-24

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 2023-09-07

F · Potential for more than minimal harm 2023-07-21

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-08-03

E · Potential for more than minimal harm 2023-07-21

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2023-08-03

E · Potential for more than minimal harm 2023-07-21

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 2023-08-03

E · Potential for more than minimal harm 2023-07-21

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-08-03

D · Potential for more than minimal harm 2023-07-21

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2023-08-03

D · Potential for more than minimal harm 2023-07-21

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2023-08-03

D · Potential for more than minimal harm 2023-07-21