Inspection Report
Annual Inspection
Deficiencies: 5
Oct 14, 2025
Visit Reason
Annual Licensure survey conducted to assess compliance with Illinois Department of Public Health regulations for assisted living facilities.
Findings
The facility was found deficient in multiple areas including employee orientation and ongoing training, communicable disease policies related to COVID-19 precautions, tuberculosis screening for employees, Alzheimer's and dementia program safety and supervision, and resident rights related to abuse and neglect prevention. Several residents and employees failed to meet training and screening requirements, and infection control measures were not properly followed. Resident supervision and safety, especially for those with dementia and aggressive behaviors, were inadequate, resulting in resident-to-resident altercations.
Severity Breakdown
Type 1 Violation: 1
Type 2 Violation: 2
Type 3 Violation: 1
General Violation: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure newly hired staff completed orientation and ongoing training within required timeframes. | Type 3 Violation |
| Failed to follow infection control precautions for residents positive for COVID-19 and failed to timely report outbreak to the Department. | Type 2 Violation |
| Failed to ensure newly hired staff completed Tuberculosis screening as required. | General Violation |
| Failed to ensure adequate supervision and safety for residents in Alzheimer's and Dementia program, resulting in elopement incidents. | Type 2 Violation |
| Failed to provide a safe environment, adequate supervision, and individualized care plan for residents with dementia and aggressive behavior, resulting in resident-to-resident abuse. | Type 1 Violation |
Report Facts
Employees reviewed: 9
Employees non-compliant with training: 3
Employees non-compliant with tuberculosis screening: 2
Residents reviewed for COVID-19 precautions: 4
Resident MMSE score: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E11 | Lifestyle Assistant | Failed to complete orientation training within required timeframe. |
| E12 | Cook | Failed to complete orientation training and tuberculosis screening within required timeframe. |
| E13 | Dietary Assistant | Failed to complete orientation training and tuberculosis screening within required timeframe. |
| E4 | Human Resource Manager | Acknowledged employees had not completed required training and tuberculosis screening. |
| E6 | Infection Preventionist | Reported infection control requirements for COVID-19 positive residents and staff. |
| E7 | Licensed Practical Nurse, Memory Care | Provided information on COVID-19 positive residents and resident R3's aggressive behavior. |
| E8 | Certified Nursing Assistant | Observed not performing hand hygiene after applying mask to COVID-19 positive resident. |
| E10 | Lifestyle Assistant | Observed assisting COVID-19 positive resident without gloves or hand hygiene. |
| E1 | Director of Assisted Living and Memory Care | Acknowledged need for closer monitoring and supervision of residents in Memory Care Unit. |
Inspection Report
Annual Inspection
Deficiencies: 2
Nov 18, 2024
Visit Reason
The inspection was conducted as an Annual Licensure Survey to assess compliance with state regulations including disaster preparedness and Alzheimer's and dementia program requirements.
Findings
The facility failed to conduct required tornado drills in February on all shifts and failed to prevent elopement incidents involving two residents with dementia, indicating deficiencies in disaster preparedness and Alzheimer's/dementia program safety measures.
Severity Breakdown
Type 3 Violation: 1
Type 2 Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to conduct tornado drills in February on all shifts as required by disaster preparedness regulations. | Type 3 Violation |
| Failure to prevent elopement of two residents with dementia, including lack of wander guards and ineffective alarm response. | Type 2 Violation |
Report Facts
Residents reviewed for elopement: 9
Number of residents involved in elopement incidents: 2
Date of tornado drill requirement: 6
Date of last tornado drill: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Interviewed regarding tornado drills and elopement incidents; unaware of tornado drill requirement. | |
| E2 | Clinical Nurse Coordinator | Provided information about residents R2 and R3 elopement incidents and wander guard usage. |
| E10 | Certified Nursing Assistant | Responded to alarm during elopement incident, silenced alarm, and provided care to other residents. |
| E11 | Licensed Practical Nurse | Nurse on duty during elopement incident; heard alarm but did not respond. |
| E13 | Receptionist | Interacted with residents during elopement and reported confusion about their identity. |
| E14 | Security Guard | Opened door allowing residents to exit during elopement incident; did not realize they were residents. |
Inspection Report
Plan of Correction
Census: 27
Deficiencies: 2
6024353 View POC 001 Oak Trace Statement of Correction 12 2 2024
Visit Reason
This document is a Statement of Correction addressing violations related to disaster preparedness and Alzheimer's and Dementia Programs at the facility.
Findings
The facility was found deficient in disaster preparedness and Alzheimer's and Dementia program requirements, including the need for tornado drills, elopement risk management, and resident safety measures.
Deficiencies (2)
| Description |
|---|
| Violation of Section 295.2040 Disaster Preparedness requiring annual tornado drills on each shift. |
| Violation of Section 295.4060 Alzheimer's and Dementia Programs requiring quality assurance performance improvement and elopement risk management. |
Report Facts
Residents in memory care: 27
Tornado drill dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eric Hammer | Director of Assisted Living and Memory Care | Signed the Statement of Correction |
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