Deficiencies (last 3 years)
Deficiencies (over 3 years)
8.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
149% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 5
Date: 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.
Deficiencies (5)
Failed to ensure newly hired staff completed orientation and ongoing training within required timeframes.
Failed to follow infection control precautions for residents positive for COVID-19 and failed to timely report outbreak to the Department.
Failed to ensure newly hired staff completed Tuberculosis screening as required.
Failed to ensure adequate supervision and safety for residents in Alzheimer's and Dementia program, resulting in elopement incidents.
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.
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
Routine
Deficiencies: 9
Date: Jan 17, 2025
Visit Reason
Routine inspection of Oak Trace nursing home to assess compliance with resident rights, care planning, bed hold policy, pressure ulcer care, accident prevention, nutrition, feeding tube care, medication administration, and food safety standards.
Findings
The facility failed to provide privacy covers for urinary catheter bags, facilitate resident participation in care planning, notify residents of bed hold policy, prevent pressure ulcer deterioration, ensure safe resident transfers, maintain adequate nutrition, correctly verify feeding tube placement, administer medications properly, and maintain kitchen food safety and sanitation standards.
Deficiencies (9)
F 0550: The facility failed to provide privacy covers for urinary catheter bags for 2 of 3 residents reviewed, exposing catheter bags in public areas.
F 0553: The facility failed to facilitate resident participation in care planning and did not hold an interdisciplinary team meeting for a resident with weight loss.
F 0625: The facility failed to provide written notification of the bed hold policy to residents and their representatives upon hospital transfer for 4 residents reviewed.
F 0686: The facility failed to prevent further deterioration of a pressure ulcer by not repositioning a resident as ordered and delaying provision of an air mattress.
F 0689: The facility failed to ensure safe resident transfers and proper positioning, including use of mechanical lifts and fall prevention interventions for 4 residents.
F 0692: The facility failed to provide adequate nutrition interventions to prevent further weight loss in a resident, resulting in severe unplanned weight loss.
F 0693: The facility failed to correctly verify gastrostomy tube placement prior to medication administration, relying on auscultation of air rather than residual checks.
F 0759: The facility failed to administer medications as ordered, crushing enteric-coated tablets, soft gels, and capsules, resulting in a medication error rate of 10.34%.
F 0812: The facility failed to maintain kitchen food safety by storing dented cans, expired yogurt, unlabeled frozen foods, and using sanitizer solutions below required concentration levels.
Report Facts
Medication error rate: 10.34
Residents affected: 99
Residents affected: 20
Weight loss: 10.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Assistant Director of Nursing/Director of Nursing | Provided statements on privacy covers, bed hold policy, pressure ulcer care, resident transfers, and medication administration |
| V4 | Dietary Manager | Provided statements and observations on kitchen food safety and sanitation |
| V8 | Registered Nurse | Observed administering medications and involved in medication errors |
| V9 | Registered Nurse | Provided statements on medication crushing and G-tube placement verification |
| V10 | RN Supervisor | Provided statements on medication crushing and G-tube placement verification |
| V15 | Registered Dietician | Provided statements on nutrition interventions for resident R35 |
| V19 | Resident R35's daughter, provided statements on nutrition and care planning |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: 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.
Deficiencies (2)
Failure to conduct tornado drills in February on all shifts as required by disaster preparedness regulations.
Failure to prevent elopement of two residents with dementia, including lack of wander guards and ineffective alarm response.
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
Complaint Investigation
Deficiencies: 2
Date: May 20, 2024
Visit Reason
The investigation was conducted due to complaints regarding unsafe resident transfers that resulted in falls and injuries to residents R1 and R3.
Complaint Details
The complaint investigation substantiated that the facility did not follow safe transfer policies, resulting in falls and injuries to residents R1 and R3. The facility's failure to have two caregivers during mechanical lift transfers and failure to use gait belts were confirmed.
Findings
The facility failed to follow its policies for safe resident transfers, resulting in R1 sustaining a fall with a subarachnoid hemorrhage and R3 experiencing a fall due to improper transfer techniques without the use of gait belts. Staff did not consistently follow protocols requiring two caregivers for mechanical lift transfers and use of gait belts during transfers.
Deficiencies (2)
F 0689: The facility failed to ensure safe transfers using the sit-to-stand mechanical lift, resulting in R1 falling and sustaining a subarachnoid hemorrhage. Two caregivers were required but only one was present during the transfer.
F 0689: The facility failed to use gait belts during transfers for R3, who required extensive assistance, leading to a fall when staff did not properly support her during transfer.
Report Facts
Date of survey completion: May 20, 2024
Fall date for R1: May 4, 2024
Fall date for R3: May 10, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V3 | Certified Nursing Assistant (CNA) | Witnessed and involved in R1's fall during mechanical lift transfer |
| V4 | Certified Nursing Assistant (CNA) | Witnessed and involved in R1's fall during mechanical lift transfer |
| V9 | Licensed Practical Nurse (LPN) | Witnessed R1 on floor after fall and documented incident |
| V2 | Director of Nursing (DON) | Provided statement regarding transfer protocol failure during R1's fall |
| V6 | Therapy Program Director | Provided assessment on R3's transfer needs and gait belt use |
| V13 | Certified Nursing Assistant (CNA) | Involved in R3's fall and transfer without gait belt |
| V14 | Registered Nurse (RN) | Documented R3's fall incident |
| V7 | Physician | Provided medical opinion on R1's fall and injury |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Feb 16, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, infection control, medication administration, dietary services, and safety in a nursing home facility.
Findings
The facility was found deficient in multiple areas including inadequate perineal and catheter care leading to potential urinary tract infections, improper PICC line dressing and monitoring, failure to follow physician orders for oxygen administration, incorrect food preparation for residents with modified diets, and lapses in infection control practices such as hand hygiene and glove use during medication administration and resident care.
Deficiencies (5)
F 0690: The facility failed to provide proper perineal and catheter care to prevent urinary tract infections for 2 of 3 residents reviewed, including inadequate cleaning of the perineum and catheter tubing.
F 0694: The facility failed to ensure the PICC line insertion site was visible and properly dressed, with an occlusive dressing improperly applied over gauze and lacking signature.
F 0695: The facility failed to follow physician orders for oxygen administration and did not label oxygen tubing and humidifier bottles as required.
F 0805: The facility failed to provide mechanically soft chili and pureed carrot cake consistent with residents' modified diet orders, serving food with inappropriate textures and ingredients.
F 0880: The facility failed to follow standard infection control practices related to hand hygiene and glove use during medication administration and resident care for 4 of 5 residents reviewed.
Report Facts
Residents reviewed: 21
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 8
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V3 | Director of Nursing | Named in findings related to PICC dressing and oxygen administration deficiencies |
| V22 | Nurse | Named in infection control deficiency related to hand hygiene and glove use during medication administration |
| V20 | Certified Nursing Assistant | Named in infection control and perineal care deficiencies |
| V21 | Certified Nursing Assistant | Named in perineal care deficiency |
| V6 | Registered Nurse | Named in oxygen administration deficiency |
| V8 | Certified Dietary Manager | Named in dietary food preparation deficiency |
| V9 | Cook | Named in dietary food preparation deficiency |
| V13 | Cook | Named in dietary food preparation deficiency |
| V5 | Infection Control Nurse | Named in infection control deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 28, 2023
Visit Reason
The inspection was conducted due to allegations of abuse involving three residents at the facility. The investigation focused on whether the facility properly reported suspected abuse to local law enforcement as required.
Complaint Details
The complaint investigation involved three residents (R1, R2, R3) with allegations of abuse. The allegations were not reported to law enforcement as required. The facility policy requires reporting preliminary allegations within two hours and contacting law enforcement if there is injury. The allegations were substantiated as the facility failed to report them properly.
Findings
The facility failed to report allegations of abuse to local law enforcement for three residents despite having policies requiring such reporting. The allegations involved rough handling and physical abuse claims, but law enforcement was not notified as there was no injury reported.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to proper authorities for three residents. The facility did not notify law enforcement as required despite allegations of abuse.
Report Facts
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V1 | Administrator and Abuse Coordinator | Conducted the investigation and made reports regarding abuse allegations |
| V2 | Director of Nursing | Received and forwarded abuse allegation notes to the Administrator |
| V7 | Registered Nurse | Read progress note regarding abuse allegation and gave it to the Director of Nursing |
| V4 | Orthopedic Doctor | Documented patient's complaint of rough handling by staff |
Inspection Report
Deficiencies: 2
Date: Mar 10, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food safety standards, specifically focusing on sanitizer concentration and proper storage, preparation, and distribution of food.
Findings
The facility failed to maintain proper sanitizer concentration in sanitizing buckets and did not discard expired or improperly labeled food items. Multiple food items in the kitchen and storage areas were found expired, moldy, or lacking required labeling.
Deficiencies (2)
F 0812: The facility failed to ensure sanitizer concentration solution met standards; one red sanitizing bucket registered 0 ppm and was not changed every two hours as required by policy.
F 0812: Multiple food items were expired, moldy, or lacked proper received, opened, or use-by dates, including bread, hamburger buns, bagels, cheese, liquid egg yolk, horseradish, pepperoni, and sauces.
Report Facts
Residents affected: 28
Hamburger buns count: 10
Bagels count: 6
Raisin bread loaves: 8
Capers jars: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Supervisor | Tested sanitizer concentration and provided statements about sanitizer bucket usage |
Inspection Report
Plan of Correction
Census: 27
Deficiencies: 2
Date: 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)
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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