Bella Terra Lombard
2100 South Finley Road, Lombard, IL 60148 · Du Page County · 224 certified beds · avg 146 residents/day · certified since Oct 1, 1985
Part of chain: LEGACY HEALTHCARE (89 facilities, chain avg rating 2.9★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5
⚠ The most recent standard health inspection was more than 2 years ago — conditions may have changed.
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Jun 25, 2026 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 6, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 24, 2023 · F-0677 · triggered by a complaint
The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Why it matters: Residents who don't get this help can suffer poor hygiene, skin breakdown, weight loss, and a loss of dignity.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 7, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (39)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 25, 2026 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Jan 28, 2026 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Jan 28, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Oct 6, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Mar 11, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Mar 11, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Jul 20, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Jul 17, 2024 | D · Potential for harm, one-off | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint |
| Jun 26, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jun 26, 2024 | E · Potential for harm, repeated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jun 26, 2024 | E · Potential for harm, repeated | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Jun 26, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jun 26, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jun 26, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jun 26, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Jun 26, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 11, 2024 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Apr 2, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Feb 21, 2024 | D · Potential for harm, one-off | The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out. · from a complaint |
| Aug 24, 2023 | ▲ G · Actual harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Jul 21, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 21, 2023 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Jul 21, 2023 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jul 21, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 21, 2023 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Jul 21, 2023 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Jul 21, 2023 | D · Potential for harm, one-off | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. |
| Apr 28, 2022 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Apr 28, 2022 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Apr 28, 2022 | E · Potential for harm, repeated | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Apr 28, 2022 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 28, 2022 | E · Potential for harm, repeated | The facility did not provide each resident with a nourishing, tasty, well-balanced diet that meets their daily nutritional and special dietary needs. |
| Apr 28, 2022 | E · Potential for harm, repeated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Apr 28, 2022 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Apr 28, 2022 | D · Potential for harm, one-off | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. |
| Apr 28, 2022 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Apr 28, 2022 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Apr 28, 2022 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 28, 2022 | D · Potential for harm, one-off | The facility did not make sure its staff were vaccinated for COVID-19 in accordance with the federal requirements in effect at the time. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (7 → 8).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 12 | 0 | E |
| 2023 | 8 | 1 | G ▲ |
| 2024 | 13 | 0 | F |
| 2025 | 3 | 0 | D |
| 2026 | 3 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Illinois avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.57 | 2.99 | 3.95 | bottom 41% in Illinois; bottom 4% in the U.S. |
| Registered Nurse hours | 0.72 | 0.63 | 0.69 | top 26% in Illinois; top 34% in the U.S. |
| Weekend total nurse staffing | 2.42 | 2.67 | 3.50 | top 47% in Illinois; bottom 7% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.88 | 0.56 | 0.48 | top 14% in Illinois; top 8% in the U.S. |
| Total nursing staff turnover (%) | 50.0 | 44.5 | 45.8 | bottom 34% in Illinois; bottom 38% in the U.S. |
| RN turnover (%) | 39.4 | 41.8 | 42.9 | top 49% in Illinois; top 46% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.40, RN 0.96, weekend 3.21. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 4/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Doros Generation Trust U/A/D 1/3/12 | Organization | 5% or Greater Direct Ownership Interest | 17% | 06/01/2021 |
| Garden, Daniel | Individual | 5% or Greater Direct Ownership Interest | 8% | 06/01/2021 |
| GPN Family Trust U/A/D 4/28/08 | Organization | 5% or Greater Direct Ownership Interest | 17% | 06/01/2021 |
| Ninio, Mordechay | Individual | 5% or Greater Direct Ownership Interest | 59% | 06/01/2021 |
| Morris, Margaux | Individual | W-2 Managing Employee | NOT APPLICABLE | 06/01/2021 |
| TBDMD Il, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 06/01/2021 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "What safeguards do you have to protect residents' money and belongings, and what happens when something goes missing?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Beacon Hill | 0.4 mi | Lombard, IL | ★★★★★ | 4/5 | |
| The Pearl of Downers Grove | 1.6 mi | Downers Grove, IL | ★☆☆☆☆ | 2/5 | |
| Alta Rehab at Oak Brook | 2.8 mi | Oak Brook, IL | ★★☆☆☆ | 2/5 | |
| Bella Terra Elmhurst | 3.9 mi | Elmhurst, IL | ★★★★☆ | 4/5 | |
| Oakwood Rehab and Nursing Center | 4.2 mi | Westmont, IL | ★☆☆☆☆ | 1/5 | abuse |
| Park Place Christian Community | 4.7 mi | Elmhurst, IL | ★★★★★ | 4/5 | |
| Pearl of Hinsdale, the | 5.0 mi | Hinsdale, IL | ★★★★☆ | 4/5 | |
| The Commons at Lisle Creek Estates | 5.1 mi | Lisle, IL | ★★★★☆ | 4/5 | |
| Burgess Square Healthcare Ctr | 5.2 mi | Westmont, IL | ★★★★☆ | 3/5 | |
| Wheaton Village Nrsg & RHB Ctr | 5.3 mi | Wheaton, IL | ★★★☆☆ | 3/5 | |
| Thrive of Lisle | 5.5 mi | Lisle, IL | ★★★★☆ | 4/5 | |
| Oak Trace | 5.8 mi | Downers Grove, IL | ★★★★★ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 145511.