Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oak Trace during CMS and state inspections, most recent first.
Medication Refrigerator Stored at Improper Temperature: A medication refrigerator in the 4 South med room was found at 59 degrees F, with warm medications inside, despite logs showing mostly 38 to 40 degrees F. Medications for several residents, including liquid lorazepam, lorazepam oral concentrate, and Zioptan eye drops, were labeled for refrigeration at 36 to 40 degrees F. The DON confirmed the temp should be 40 degrees F or under, and Maintenance stated the unit had likely been set to the warmest setting for a couple of days.
A resident experienced severe weight loss due to the facility's failure to implement adequate nutritional interventions. Despite the resident's known preference for a specific supplement, it was not consistently provided, and meals were sometimes left untouched. The facility did not conduct an IDT meeting to address the resident's change in condition, and the policy on weight assessments was not followed.
The facility failed to maintain proper food storage and sanitization practices, affecting 99 residents. Dented cans and improperly labeled food items were found in storage, contrary to facility policy. Sanitization buckets in the kitchen had inadequate sanitizer levels, posing a risk of foodborne illness. The Dietary Manager acknowledged these issues, but there was no documentation of specific sanitizer levels, and the manager was unaware of prior dispenser issues.
The facility failed to provide written notification of its bed hold policy to residents and their representatives during hospital transfers. In four cases, residents were transferred to the hospital for medical emergencies, but there was no documentation of written notification. Staff interviews confirmed that while verbal notifications were sometimes given, written documentation was not provided as required.
The facility failed to ensure safe transfers and fall prevention for residents at risk for accidents. A resident was improperly positioned in a wheelchair, another lacked a required floor mat, and a third had an unsecured mattress topper. Additionally, a CNA conducted a mechanical lift transfer alone, against policy requiring two staff members.
The facility failed to provide privacy covers for urinary catheter bags for two residents, compromising their dignity and privacy. One resident with an indwelling catheter due to bladder neoplasm and another with a suprapubic catheter for obstructive uropathy were observed in the dining room without privacy covers, exposing their catheter bags. The ADON acknowledged the expectation for staff to maintain residents' dignity by providing privacy covers.
A resident with cognitive impairment and significant weight loss was not included in the development of his care plan, nor was an IDT meeting held to address his condition. Despite the facility's policy and the resident's daughter's request for a care-plan meeting, the facility failed to schedule one, resulting in a deficiency in resident rights and care planning.
A resident with multiple chronic conditions and a stage 3 sacral pressure ulcer experienced further deterioration of the ulcer due to the facility's failure to consistently implement repositioning and timely provision of a pressure-relieving mattress. Despite a care plan and facility policy requiring repositioning every two hours, the resident was left in a wheelchair for an extended period without repositioning, contributing to the worsening of the ulcer.
A facility failed to verify G-tube placement correctly before administering medications to a resident. Staff used air injection and auscultation methods, which did not align with the facility's policy requiring pH measurement of gastric secretions. The resident had a history of surgical aftercare and gastrostomy status.
The facility failed to administer medications correctly, resulting in a 10.34% error rate. An RN crushed medications that should not have been crushed, including Amoxicillin-Pot Clavulanate and PreserVision AREDS 2 soft gel for a resident, and Terazosin for another resident. The RN admitted to the errors, and staff confirmed the medications should not have been crushed, leading to deficiencies in medication administration.
The facility failed to follow transfer policies, resulting in falls and injuries for two residents. One resident, with severe cognitive impairment, fell during a sit-to-stand mechanical lift transfer when one CNA left the room, leaving the other CNA to complete the transfer alone. Another resident, also with severe cognitive impairment, was transferred without a gait belt, leading to a fall when her knees buckled.
Medication Refrigerator Stored at Improper Temperature
Penalty
Summary
The facility failed to store medications within appropriate temperature parameters in the medication refrigerator. During an inspection of the 4 South medication room on the 4th floor, the refrigerator thermometer showed 59 degrees F even though the temperature log mainly showed temperatures between 38 and 40 degrees. The refrigerator felt warm and the medications inside were warm to the touch. The medications stored in the refrigerator included liquid Lorazepam for R4, Zioptan (Tafluprost Ophthalmic) eye drops for R26, Lorazepam Oral Concentrate for R27, liquid Lorazepam for R47, and liquid Lorazepam Intensol for R60. The labels on these medications indicated they were to be refrigerated or stored at cold temperatures between 36 and 40 degrees F. The DON stated the residents were still in the facility and their POS showed orders for these medications. Maintenance later checked the refrigerator and stated someone had turned it to the warmest setting, likely for a couple of days, and confirmed the refrigerator should be at 40 degrees F or under.
Failure to Maintain Resident's Nutritional Status
Penalty
Summary
The facility failed to ensure that a resident, identified as R35, maintained an acceptable nutritional status, resulting in unplanned weight loss. R35, a male resident with cognitive impairment and multiple health conditions, experienced a severe weight loss of 10.1 pounds over one month. Despite the facility's knowledge of this weight loss, there were no adequate interventions implemented to address the decline. The facility offered oral nutritional supplements, snacks, and smoothies, but did not include the resident's preferred 'magic cup' in the dietary plan, which was known to be well-received by the resident. The Registered Dietician (RD) acknowledged that no new interventions were in place to address the weight loss, and the Medical Director relied on the RD's recommendations for nutritional supplements. Observations and interviews revealed that the resident appeared thin and frail, and there were instances where meals were left untouched or not provided. The resident's daughter expressed concerns about her father's nutritional intake and noted that the facility had not scheduled a care-plan meeting despite her requests. The facility's policy on weight assessments and interventions was not followed, as there was no Interdisciplinary Team (IDT) meeting conducted to address the resident's change in condition. The lack of timely and appropriate interventions contributed to the resident's continued weight loss and potential decline in health.
Deficiencies in Food Storage and Sanitization Practices
Penalty
Summary
The facility failed to maintain its kitchen in a manner that prevents foodborne illness, affecting 99 residents receiving dietary services. During a kitchen tour, several deficiencies were observed, including the presence of dented cans of food, such as pinto beans, great northern beans, and pears, which were not stored in a designated area for distressed products as per facility policy. Additionally, a 20-pound tub of cherry pie filling was found opened without a delivery or use-by date, contrary to the facility's policy requiring such items to be dated and refrigerated. The walk-in cooler contained expired vanilla Greek yogurt, and the walk-in freezer had various meat products and shrimp without proper labeling or dating, which is against the facility's food storage policy. The facility's sanitization practices were also found to be inadequate. Red sanitization buckets used in the kitchen were tested and found to have sanitizer levels of 100 ppm, below the required 200-400 ppm range specified by the facility's policy. The Dietary Manager and Chef were unaware of any prior issues with the sanitizer dispenser, and the facility's Red Bucket Logs did not record the specific parts per million level of the sanitizer, only that it was in range. This lack of proper sanitization could potentially lead to cross-contamination and foodborne illness among residents. The Dietary Manager acknowledged that dented cans should not be used and that food items should be properly dated to ensure they are safe for consumption. The manager also stated that the sanitizer dispenser was not dispensing the correct amount of sanitizer, and the red sanitization buckets should be changed every two hours. However, the manager was unable to explain why the sanitizer levels were not within the required range, and there was no documentation to indicate the specific sanitizer levels. These deficiencies in food storage and sanitization practices pose a risk of foodborne illness to the residents served by the facility's dietary services.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed hold policy to residents and their representatives during hospital transfers. This deficiency was identified in four cases where residents were transferred to the hospital for various medical emergencies, including a urinary tract infection, low hemoglobin, acute health changes, and gastrointestinal issues requiring surgery. In each instance, the facility did not have documentation showing that the residents or their representatives received the required written notification of the bed hold policy at the time of transfer. Interviews with facility staff revealed that while nurses sometimes verbally informed residents and their families about the bed hold policy, they did not provide written documentation as required. The Assistant Director of Nursing confirmed the absence of written notifications in the residents' electronic medical records. The facility's administrator acknowledged that all residents should receive written notification of the bed hold policy upon admission and during any leave, including hospitalizations, and that these forms should be uploaded to the residents' records once completed.
Failure to Ensure Safe Transfers and Fall Prevention
Penalty
Summary
The facility failed to ensure safe transfer and positioning for residents at risk for accidents. Resident R48, who was at high risk for falls due to cognitive and physical impairments, was observed in a dining room slouched in a wheelchair with a mechanical lift sling improperly positioned underneath him. Despite his discomfort and attempts to adjust himself, staff did not promptly assist him. Later, staff used a sit-to-stand lift instead of the recommended total-mechanical lift for transferring R48, which was against the facility's policy requiring two staff members for such transfers. Resident R60, who had a history of falling from bed, was found without the required floor mat intervention in place, which was supposed to be on the side of the bed he favored. The floor mat was instead folded against the bathroom wall, indicating a failure to implement the necessary fall prevention measures as outlined in his care plan. This oversight was acknowledged by the Assistant Director of Nursing, who confirmed the expectation for staff to follow fall prevention interventions. Resident R9 was observed in bed on an unsecured foam mattress topper, which was placed on top of an air-loss mattress. This setup was not properly assessed or secured, posing a risk of sliding off. The Assistant Director of Nursing later assessed and removed the topper for safety reasons. Additionally, a CNA was observed transferring Resident R18 using a mechanical lift without the assistance of a second staff member, contrary to the facility's policy requiring two staff members for such procedures. An RN present during the transfer confirmed the policy and acknowledged the breach in protocol.
Failure to Provide Privacy Covers for Urinary Catheter Bags
Penalty
Summary
The facility failed to provide privacy covers for urinary catheter bags for two residents, compromising their dignity and privacy. Resident R10, who required an indwelling urinary catheter due to acute urinary retention related to malignant neoplasm of the bladder, was observed in the dining room on two separate occasions without a privacy cover for her catheter bag. The bag was visibly exposed with dark-red urine, highlighting a lack of privacy and dignity in her care. R10 was dependent on facility staff for toileting hygiene needs, as noted in her MDS. Similarly, Resident R60, who used a suprapubic urinary catheter for obstructive uropathy related to benign prostatic hyperplasia, was also observed without a privacy cover for his catheter bag. On one occasion, a CNA transported R60 to the dining room, where his catheter bag was exposed with amber urine. The Assistant Director of Nursing acknowledged the expectation for staff to provide privacy bags to maintain residents' dignity. The facility's policy emphasizes the importance of treating residents with respect and ensuring privacy in their care, which was not upheld in these instances.
Failure to Facilitate Resident Participation in Care Planning
Penalty
Summary
The facility failed to uphold resident rights by not facilitating the participation of a resident, identified as R35, in the development and implementation of his person-centered care plan. R35, a male resident with cognitive impairment and several medical conditions, including a severe weight loss of 10.1 lbs. over a month, was not included in an Interdisciplinary Team (IDT) meeting to address his care needs. Despite the facility's policy requiring an IDT meeting within three days of admission and upon any significant change in condition, no such meeting was held for R35. His daughter, V19, expressed concerns about his weight loss and requested a care-plan meeting, which was not scheduled by the facility. The interim Director of Nursing (DON) acknowledged that R35 was considered a short-term care resident and confirmed that an IDT meeting should have been conducted due to the significant weight loss, which was recognized as a change in condition. The facility's failure to conduct an IDT meeting and revise R35's care plan in response to his weight loss and the family's request for a meeting constitutes a deficiency in resident rights and care planning. The facility's policy on care planning, which mandates the development of an individualized comprehensive care plan for each resident, was not followed in this instance.
Failure to Prevent Deterioration of Pressure Ulcer
Penalty
Summary
The facility failed to implement adequate measures to prevent the deterioration of a pressure ulcer for a resident, identified as R91, who was readmitted from a hospital stay with multiple diagnoses including a wedge compression fracture, dysphagia, acute respiratory failure, and chronic conditions such as type 2 diabetes and chronic kidney disease. Upon readmission, R91 had a stage 3 sacral pressure ulcer, which was documented to have worsened significantly over time. Despite the presence of a care plan that included interventions such as repositioning every two hours, the use of pressure-reducing devices, and nutritional support, these measures were not consistently implemented. On the day of the survey, R91 reported having been in a wheelchair since 7:30 am without being repositioned, which was confirmed by the CNA assigned to him. The facility's interim DON and wound nurse both acknowledged the importance of repositioning every two hours to prevent further deterioration of pressure ulcers. However, the documentation revealed that R91 was not repositioned for an extended period, from 7:30 am to 11:54 am, which is contrary to the facility's policy and contributed to the worsening of his condition. The facility's policy on the prevention of pressure ulcers emphasizes the need for regular repositioning and comprehensive skin assessments. Despite this, there was no documentation of repositioning for R91, and the air mattress, which was verbally requested by the wound nurse on 12/31/24, was not ordered until 1/9/25. This delay, along with the lack of consistent repositioning, contributed to the deterioration of R91's pressure ulcer, highlighting a deficiency in the facility's care practices for residents with pressure ulcers.
Failure to Verify G-Tube Placement Correctly
Penalty
Summary
The facility failed to correctly verify the placement of a G-tube before administering medications to a resident. On January 15, 2025, a registered nurse (RN) was observed administering medications through a G-tube by injecting air into the tube and listening for sounds, a method that was repeated the following day. Another RN confirmed using the same method of pushing air and listening for bubbling sounds to verify G-tube placement. The RN Supervisor also stated that they checked placement by pushing air and listening for gurgling sounds. However, the Director of Nursing (DON) mentioned that checking for residual was part of the procedure, but did not align with the facility's policy. The resident involved, identified as R91, was admitted with diagnoses including surgical aftercare following digestive system surgery and gastrostomy status. The facility's policy for verifying feeding tube placement, dated 2024, required measuring the pH of gastric secretions by aspirating gastric contents and using a pH strip, which was not followed by the staff. This discrepancy between the facility's policy and the staff's practice led to the deficiency in ensuring the correct placement of the G-tube before medication administration.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 10.34%, which is above the acceptable threshold of 5%. During the observation of medication administration, a registered nurse (RN) crushed medications that should not have been crushed. Specifically, the RN crushed Amoxicillin-Pot Clavulanate and PreserVision AREDS 2 soft gel for a resident, despite these medications being on a list of oral dosage forms that should not be crushed. The RN admitted to the error, acknowledging that the medications should have been melted or put on hold instead of being administered in a crushed form. In another instance, the same RN crushed a Terazosin capsule for a different resident and administered it through a G-tube, which was not the correct method of administration. The RN later acknowledged that the capsule should have been opened or melted, and that a doctor should have been consulted to change the medication. The Director of Nursing and other staff confirmed that the medications in question should not be crushed, and the facility's policy required verification of the correct method of administration before giving medications. These actions led to the identified deficiencies in medication administration.
Failure to Follow Transfer Policies Resulting in Resident Falls
Penalty
Summary
The facility failed to follow their policy to ensure residents were safely transferred, resulting in a fall and subsequent hospitalization of a resident with a subarachnoid hemorrhage and contusion of the brain. The incident involved a resident with severe cognitive impairment and multiple diagnoses, including dementia and muscle weakness. During a transfer using a sit-to-stand mechanical lift, the resident slipped out of the sling and fell, hitting her head. The transfer was initially started with two CNAs, but one CNA left the room, leaving the other CNA to complete the transfer alone, contrary to the facility's policy requiring two staff members for such transfers. Another incident involved a resident with severe cognitive impairment and a history of falls. The resident was being transferred from bed to chair by a CNA who did not use a gait belt, as required by the facility's policy. The resident's knees buckled during the transfer, and the CNA lowered her to the floor. The CNA admitted to not being trained on the necessity of using a gait belt for transfers and stated that the nurse present did not correct the improper transfer technique. Both incidents highlight a failure to adhere to established safety protocols for resident transfers, resulting in falls and potential harm. The facility's policies clearly state the need for two staff members during mechanical lift transfers and the use of gait belts for certain residents, but these protocols were not followed, leading to the deficiencies noted in the report.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Downers Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bria Of Westmont | 1 mi | ★★★★★ | 14 | 0 |
| Burgess Square Healthcare Ctr | 1.4 mi | ★★★★★ | 10 | 0 |
| Chateau Nrsg & Rehab Center | 3 mi | ★★★★★ | 2 | 0 |
| Eden Vista Burr Ridge | 3.2 mi | ★★★★★ | 7 | 0 |
| Oakwood Rehab And Nursing Center | 3.4 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.