3 Reports
Inspection Report — Oct 14, 2025
Annual Inspection
Date: Oct 14, 2025
Visit Reason
Annual Licensure survey combined with Facility Reported Incident IL197793 of September 14, 2025.
Findings
The facility was found to have multiple deficiencies including delayed employee orientation and tuberculosis screening, failure to follow infection control precautions for Covid-19 positive residents, inadequate supervision of residents with dementia, and failure to prevent resident-to-resident abuse.
Deficiencies (5)
A3020 (295.3020 Employee Orientation and Ongoing Training) - The facility failed to ensure three of nine newly hired employees completed their orientation training within the required timeframe.
A4040 (295.4040 Communicable Disease Policies) - The facility failed to follow infection control precautions for four Covid-19 positive residents and failed to report the outbreak to the Department timely.
A4050 (295.4050 Tuberculin Skin Test Procedures) - The facility failed to ensure two of nine newly hired employees completed their tuberculosis screening.
A4060 (295.4060 Alzheimer's and Dementia Programs) - The facility failed to ensure adequate supervision and safety for one resident with dementia who eloped twice, and failed to update the resident's service plan accordingly.
A6000 (295.6000 Resident Rights) - The facility failed to provide a safe environment and adequate supervision for residents with dementia, resulting in a resident-to-resident physical altercation where one resident punched another in the face.
Report Facts
Employees affected: 3
Employees affected: 2
Residents affected: 4
Residents affected: 1
Residents involved: 2
Inspection Report — Nov 18, 2024
Annual Inspection
Date: Nov 18, 2024
Visit Reason
Annual Licensure Survey
Findings
The establishment was found to have deficiencies in disaster preparedness and Alzheimer's and dementia program requirements, including failure to conduct tornado drills on all shifts in February and failure to prevent elopement of two residents on the dementia floor.
Deficiencies (2)
A2040 (295.2040 Disaster Preparedness) - The establishment failed to ensure tornado drills were conducted in February on all shifts as required.
A4060 (295.4060 Alzheimer's and Dementia Programs) - The establishment failed to prevent elopement by two residents at high risk for elopement, with incidents involving disabled alarms and lack of wander guards.
Report Facts
Residents affected: 2
Inspection Report — 6024353 View POC 001 Oak Trace Statement of Correction 12 2 2024
Plan of Correction
Date: 6024353 View POC 001 Oak Trace Statement of Correction 12 2 2024
Visit Reason
This plan of correction responds to the violations cited in the survey of Section 295.2040 Disaster Preparedness and Section 295.4060 Alzheimer's and Dementia Programs.
Findings
The facility committed to conduct monthly tornado drills involving all shifts and residents, maintain written evaluations of drills, implement a Quality Assurance Performance Improvement plan for elopement risks, place wander guards, update resident orders, install emergency exit alarms, and provide ongoing staff in-services and maintenance inspections related to Alzheimer's and Dementia care.
5 CMS Surveys
Inspection Report — Jan 17, 2025
Annual Inspection
Date: Jan 17, 2025
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies including failure to provide privacy for catheter bags, inadequate care planning and weight loss interventions, unsafe resident handling, medication administration errors, and food safety violations. The facility failed to maintain proper food storage and sanitization standards, and did not ensure safe medication crushing and feeding tube placement verification.
Deficiencies (9)
F0550 - The facility failed to provide privacy covers for urinary catheter bags for two residents.
F0553 - The facility failed to facilitate resident participation in care-plan development and failed to hold an IDT meeting after significant weight loss for one resident.
F0625 - The facility failed to provide written notification of the bed hold policy to residents and their representatives upon hospital transfer for four residents.
F0686 - The facility failed to implement measures to prevent deterioration of a pressure ulcer for one resident, including failure to reposition and document care.
F0689 - The facility failed to ensure safe resident handling and positioning, including improper use of mechanical lifts and unsecured mattress covers for four residents.
F0692 - The facility failed to provide adequate nutritional interventions to prevent further weight loss for one resident.
F0693 - The facility failed to correctly check gastrostomy tube placement prior to medication administration for one resident.
F0759 - The facility failed to administer medications as ordered, including crushing medications that should not be crushed, resulting in a 10.34% medication error rate.
F0812 - The facility failed to maintain the kitchen in a manner to prevent foodborne illness, including storing dented cans, expired foods, unlabeled and undated food items, and sanitizer levels below required standards.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents observed: 10
Medication errors: 3
Medication opportunities: 29
Residents served: 99
Inspection Report — May 20, 2024
Date: May 20, 2024
Visit Reason
The document is a survey report for Oak Trace completed on 05/20/2024. The Initial Comment block is not present in the provided pages, so the inspection_type is set to 'other'.
Findings
The facility failed to follow policies for safe resident transfers, resulting in a resident fall with serious injury and inadequate use of gait belts during transfers.
Deficiencies (1)
F0689 - The facility failed to ensure safe transfers using mechanical lifts and gait belts, resulting in a resident (R1) sustaining a fall with subarachnoid hemorrhage and another resident (R3) falling due to improper transfer techniques.
Report Facts
Residents affected: 2
Inspection Report — Feb 16, 2024
Date: Feb 16, 2024
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, inspection_type is set to 'other'.
Findings
The survey identified multiple deficiencies related to resident care, including inadequate perineal and catheter care, improper IV fluid administration, failure to follow oxygen administration orders, incorrect food consistency for modified diets, and lapses in infection prevention practices such as hand hygiene and glove use.
Deficiencies (5)
F0690 - The facility failed to provide perineal and catheter care in a manner that would prevent urinary tract infection for 2 of 3 residents reviewed.
F0694 - The facility failed to ensure the PICC line insertion site was visible and properly monitored for signs of infection for 1 of 3 residents reviewed.
F0695 - The facility failed to follow physician's orders for oxygen administration and failed to label oxygen nasal cannula tubing and humidifier bottle for 1 resident reviewed.
F0805 - The facility failed to provide mechanical soft chili and pureed carrot cake in appropriate consistencies for 8 residents with modified diet consistencies.
F0880 - The facility failed to follow standard infection control practices related to hand hygiene and gloving during medication administration and peri-care for 4 of 5 residents reviewed.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 8
Residents affected: 4
Inspection Report — Jun 28, 2023
Complaint Investigation
Date: Jun 28, 2023
Visit Reason
Complaint investigation of alleged abuse for three residents.
Complaint Details
Complaint # not explicitly stated in the text; investigation found failure to report abuse allegations for three residents.
Findings
The facility failed to timely report allegations of abuse to local law enforcement for three residents as required by policy.
Deficiencies (1)
F0609 (Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities) - The facility failed to follow their policy by not reporting allegations of abuse to local law enforcement for three residents.
Report Facts
Residents affected: 3
Inspection Report — Mar 10, 2023
Date: Mar 10, 2023
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, the inspection type is classified as 'other'.
Findings
The facility failed to maintain proper sanitizer concentration and discarded expired food items, affecting all 28 residents consuming food in the facility. Multiple food items were found expired, unlabeled, or improperly stored.
Deficiencies (1)
F0812 - The facility failed to ensure sanitizer concentration solution met standards and failed to discard expired food items, affecting all 28 residents consuming food.
Report Facts
Residents affected: 28
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