Oak Trace
Downers Grove, Illinois · CCN 145804
21 surveys since 2010, 8 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 52
- Surveys
- 21
- Harm or worse
- 8
- Immediate jeopardy
- 0
Findings where a surveyor recorded actual harm to a resident.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 104
- Ownership
- Non profit - Corporation
- Chain
- LIFESPACE COMMUNITIES
- County
- Du Page
- Medicare-certified since
- 1994
CMS ratings
- Overall
- 5
- Health inspection
- 4
- Staffing
- 5
- Quality measures
- 5
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded somewhat fewer weighted findings than its peer group.
Weighted by harm level, against 16 not-for-profit facilities of 100–127 beds in Illinois.
Last survey on record
Mar 20, 2026
234 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 4.30 | 4.30 |
| Registered-nurse hours per resident day | 1.57 | — |
| Annual nurse turnover | 39.3% | 39.8% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $13,780 across 1 penalty
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G212.5% | H— | I— |
| No harm, potential for more than minimal | D850.0% | E531.3% | F16.3% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6892×
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F5501×
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- F5531×
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
- F6251×
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
- F6861×
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
In the surveyor’s words
From the most serious findings on record at Oak Trace, in the surveyor’s own words.
- Actual harm, isolatedF692Jan 17, 2025
Based on observation, interview, and record review, the facility failed to ensure resident maintained acceptable nutritional status. Facility failed to provide adequate interventions to prevent further decline in resident's body weight. This failure resulted in R35 experiencing unplanned weight loss. This applies to 1 of 20 residents reviewed for nutrition and hydration in a sample of 20. Findings include: R35's face-sheet showed R35 is a [AGE] year old male admitted to the facility on [DATE] with diagnoses to include unspecified fall with left sub-trochanteric fracture, chronic obstructive pulmonary disease, dementia and hypertensive heart disease. R35's MDS (Minimum Data Set) dated 12/4/24 showed, R35 had cognitive impairment and was dependent for ADLs (activities of daily life). […]
- Actual harm, isolatedF689May 20, 2024
Based on interview and record review, the facility failed to follow their policy to ensure residents were safely transferred. This failure resulted in R1 sustaining a fall and being hospitalized with a subarachnoid hemorrhage/contusion of the right side of the brain. This applies to 2 of 3 residents (R1, R3) reviewed for falls in the sample of 3. The findings include: 1. On May 15, 2024 at approximately 2:15 PM, R1 was lying in bed in her room. R1 was unable to answer questions due to her cognitive status. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. The EMR continues to show R1 was transferred to the local hospital on May 4, 2024 following a fall and returned to the facility on [DATE]. […]
- Actual harm, isolatedF689Mar 31, 2022
Based on observation, interview and record review, the facility failed to provide safety measures for a resident while being turned /repositioned during provision of care. These failures resulted in R9 sustaining a fracture of the nose from a fall incident. This applies to 1 of 3 residents (R9) reviewed for high risk for falls. The findings include: The EMR (Electronic Medical Record) shows that R9, a [AGE] year-old, was originally admitted to the facility on [DATE], was sent out to the hospital on 3/2/2022 due to lethargy and was readmitted back to the facility in 3/11/2022. R9 has diagnoses including [CONDITION(S)] episode, spinal stenosis, diabetes type II, [CONDITION(S)], hypertension, [CONDITION(S)] and dependence on hemodialysis, pulmonary embolism, and [CONDITION(S)]. […]
- No harm, potential for more than minimal, widespreadF812Jan 17, 2025
Based on observation, interview and record review the facility failed to maintain the kitchen facility in a manner to prevent foodborne illness. This applies to 99 residents in the facility receiving dietary services. Findings include: On [DATE] at 03:13 PM, V2 DON (Interim Director of Nursing) confirmed 99 residents were being served from dietary services on entry to the facility [DATE]. On [DATE] at 10:33 AM, the kitchen tour began in the lower-level kitchen with V4 Dietary Manager The dry storage contained: A dented can of pinto beans 6 pounds 15 ounces A dented can of great northern beans 6lbs 15 ounces A dented can of pears 6.56 pounds Two dented cans of pear halves 6.56 pounds. A 20lb tub of cherry pie filling opened in use no delivery date, opened on or use by date. […]
- No harm, potential for more than minimal, widespreadF812Mar 10, 2023
Based on observation, interview, and record review the facility failed to ensure sanitizer concentration solution met standards and failed to discard expired food items. This applies to all 28 residents that consume food in the facility. Findings Include: 1. On [DATE] at 02:44 PM, V3 Food Service Supervisor tested the red sanitization buckets using Hydrion QT - 40 test strips. One red sanitizing bucket registered 0 ppm (parts per million). V3 stated it was sitting too long and that's why it read 0 ppm. On [DATE] at 11:57 AM, V3 stated the test log for the three-compartment sink is used for the sanitization buckets as well. V3 stated they were using that bucket yesterday and they didn't change that bucket every two hours as they were supposed to. […]
Read 25 findings in full →The most serious and the most recent: 25 of 52 on record.
Every survey on record
FindingsAt actual harm or above
- Mar 20, 2026Standard1 finding
- Jan 17, 2025Standard9 findings · 1 harm
- May 20, 2024Complaint1 finding · 1 harm
- Feb 16, 2024Standard5 findings
- Jun 28, 2023Complaint1 finding
- Mar 10, 2023Standard1 finding
- Mar 31, 2022Complaint1 finding · 1 harm
- Dec 10, 2021Standard2 findings
Show the 13 earlier surveys
- Oct 15, 2019Complaint1 finding
- Sep 27, 2018Standard1 finding
- Aug 17, 2017Standard2 findings
- Oct 20, 2016Standard2 findings
- Sep 24, 2015Standard4 findings
- Jul 29, 2015Complaint1 finding
- Aug 29, 2014Standard4 findings
- Oct 24, 2013—2 findings
- Nov 16, 2012—3 findings
- Dec 2, 2011—5 findings · 2 harm
- May 23, 2011—1 finding
- Apr 18, 2011—3 findings · 3 harm
- Oct 1, 2010—2 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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