Oak Trace
250 Village Drive, Downers Grove, IL 60516 · Non profit - Corporation · 104 certified beds · (630) 769-6200 Medicare only — no Medicaid
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- a high payroll-based staffing rating (5/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 2 actual-harm citations
- a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $13,780 in federal fines (most recent 2025-01-17)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 4 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 8.6% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 8.9% | 6.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.7% | 54.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.1% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 14.2% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 2.9% | 18.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.2% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 15.5% | 20.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.9% | 21.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.3% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 89.9% | 63.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 20.1% | 26.1% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 8.1% | 13.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.40 | 2.02 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.73 | 2.22 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
64.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 634 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 75.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 284 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.47 therapist hours per resident per day in 2026Q1 — more than 78% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 25% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 64.6%CMS range 60.0–67.4 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.3%CMS range 9.6–14.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 75.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 87.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 65.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 99.1% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.3% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.2% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.9%CMS range 5.7–9.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.90 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 104 beds and averages 101.4 residents a day — about 98% occupied, or roughly 3 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.30 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.59 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.84 hrs/resident/day on weekends vs 4.49 on weekdays — 14% thinner on weekends. RN hours go from 1.65 to 1.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
16 citations, most serious first — scroll within the box to see all.
- Actual harm · G2025-01-17 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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). Progress notes dated 1/16/25 at 1:59 PM showed R35 lost about 10.1 lbs. in one month (12/16/24 to 1/15/25), which is -6.7% = Severe weight loss. Weight log: 1/16/2025 142.3 Lbs. 1/7/2025 144.7 Lbs. 1/2/2025 144.7 Lbs. 1/1/2025 145.6…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-05-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 May 5, 2024. R1 has multiple diagnoses including, anorexia, unsteadiness on feet, weakness, dementia, lack of coordination, muscle weakness, dysphagia, major depressive disorder, head laceration, hypertension, and glaucoma. R1's MDS (Minimum Data Set) dated April 4, 2024 shows R1 has severe…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-03-20 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store medications within appropriate temperature parameters in the medication refrigerator.This applies to 5 of 5 residents (R4, R26, R27, R47, R60) reviewed for medications in a sample of 29.The findings include:On 3/18/2026 at 9:40 AM, the 4 South medication room on the 4th floor was inspected with V2 (DON-Director of Nursing). The thermometer in the medication refrigerator showed the temperature to be 59 degrees F (Fahrenheit), despite the temperature log showing temperatures mainly between 38 and 40 degrees. The refrigerator felt warm and the medications were warm to touch.The following medications were in the refrigerator:1.R4 had liquid Lorazepam 2 MG/ML (Milligrams/Milliliters). On the front of the box, it says to store at cold temperature. Refrigerate at 2 to 8 Celsius (36 to 40 Fahrenheit).2.R26 had Zioptan (Tafluprost Opthalmic) eye drops. On the box, it says store refrigerated 2 to 8 degrees Celsius (36 to 40 Fahrenheit). 3.R27 had Lorazepam Oral Concentrate 2 MG/ ML. On the box, it says store at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-01-17 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
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 01/14/25 at 03:13 PM, V2 DON (Interim Director of Nursing) confirmed 99 residents were being served from dietary services on entry to the facility 01/14/25. On 01/14/25 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. The facility policy Production, Purchasing, Storage - Receiving dated 1/25 states date foods prior to placing in storage areas. Store distress / recalled products in a separate, designated area, marked with a sign return to supplier. The facility policy Production, Purchasing, Storage -Food and Supply…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-17 · tag F0625 — patternNotify 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide residents and their representatives a written notification of the facility's bed hold policy when transferred to the hospital. This applies to 4 out of 4 (R307, R58, R77, R6) residents reviewed for hospitalization in a sample of 20. Findings include: 1. R6's EMR (Electronic Medical Record) said she was her own responsible party, and her family member was her emergency contact/POA (Power of Attorney). R6's EMR said she required an emergency transfer to the hospital on 1/11/2025 and was currently admitted for a urinary tract infection. R6's late entry Progress Note dated 1/11/2025 said R6 was noted with change in her mentation, weakness, tremors, flushed face, and low blood pressure. The note continued to say R6 was transferred to the hospital and her POA was notified. The facility does not have documentation to show R6 and her representative were provided written notification of the facility's bed hold policy at the time of her hospital…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-01-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to safely transfer, position, implement fall interventions, and secure a mattress cover for residents (R9, R18, R48, R60) at risk for accidents. This applies to 4 out of 4 residents (R9, R18, R48, R60) reviewed for accidents in a sample of 20. Findings include: 1. R48's Care Plan dated 1/15/2025 said he was a high risk for falls related to safety awareness deficiency, anti-anxiety medication use, debilitating cardio-respiratory conditions, and cognitive deficit. The Care Plan had a goal for R48 not to sustain a serious injury. The Care Plan had active interventions to Anticipate and meet the resident's needs .The resident needs prompt response to all requests for assistance initiated on 12/18/2024. R48's Care Plan said he needed assistance with his ADLs (Activities of Daily Living) including transfers and mobility. The Care Plan showed, [R48] has fluctuation in physical abilities and it was recommended he use a total-mechanical lift device and be assisted with his mobility. On 1/14/2025 at 11:00 AM, R48 was in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-17 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide privacy covers for residents requiring the use of urinary catheter bags. This applies to 2 out of 3 residents (R10 and R60) reviewed for privacy in a sample of 20. Findings include: 1. R10's EMR (Electronic Medical Record) said R10 required an indwelling urinary catheter for acute urinary retention related to malignant neoplasm of the bladder. R10's MDS (Minimum Data Set) dated 12/17/2024 said R10 was dependent on the facility staff for her toileting hygiene needs. On 1/14/2025 at 11:00 AM, R10 was in the dining room for lunch with other residents and visitors. R10's urinary catheter bag was attached to the bottom of her high-back wheelchair. R10 did not have a privacy covering her urinary catheter bag. R10's urinary catheter bag was exposed with dark-red urine. On 1/15/2025 at 8:55 AM, R10 was in the dining room for breakfast with other residents and visitors. R10 did not have a privacy covering her urinary catheter bag. R10's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-17 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to facilitate resident rights to participate in the development of person centered care-plan and the right to request revisions to the care-plan. This applies to 1 of 20 residents reviewed for resident rights in a sample of 20. Findings include: R35's face-sheet showed, he 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). Progress notes dated 1/16/25 at 1:59 PM showed R35 lost about 10.1 lbs. in one month (12/16/24 to 1/15/25), which was -6.7% = Severe weight loss. Weight log: 1/16/2025 142.3 Lbs. 1/7/2025 144.7 Lbs. 1/2/2025 144.7 Lbs. 1/1/2025 145.6 Lbs. 12/16/2024 152.4 Lbs. Skilled Nursing Evaluation dated 12/3/24 showed, cardiovascular -…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement measures to prevent the further deterioration of a pressure ulcer. The applies to 1 of 4 residents R91 reviewed for pressure ulcers in the sample of 20. Findings include: R91 readmitted to the facility from a hospital stay on 12/12/24 with diagnoses that includes wedge compression fracture, dysphagia, acute respiratory failure, weakness, type 2 diabetes, gout, anemia and chronic kidney disease. R91's MDS (Minimum Data Set) dated 12/19/24 indicates he is cognitively intact. MDS indicates R91 is dependent on staff for his Activities of Daily Living, toileting and transferring between the wheelchair and bed. The MDS section M documents skin / ulcer treatments pressure reducing device for chair, pressure reducing device for bed, nutrition or hydration intervention to manage skin problems, pressure ulcer / injury care, application of non-surgical dressings and application of ointments / medications. On 01/16/25 at 11:07 AM, R91 was sitting up in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-17 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to correctly check G-tube (Gastrostomy) placement prior to administration of medications. This applies to 1 of 1 resident (R91) reviewed for G-tubes in a sample of 20. The findings include: On January 15, 2025 at 9:17 AM, V8 (RN/Registered Nurse) was administering medications for R91 through the G-tube. V8 drew air into a syringe and pushed the air into the G-Tube site while listening for sounds. V8 then administered R91's medications via the G-Tube. On January 16, 2025 at 9:26 AM, V8 said she would check placement by pushing 30 Milliliters of air and auscultating like she had yesterday. V8 then said she checked for residual. On January 16, 2025 at 9:01 AM, V9 (RN) said they checked placement for the G-Tube by putting the stethoscope to their stomach and pushing air and listening for bubbling sounds to verify placement. On January 16, 2025 at 9:16 AM, V10 (RN Supervisor) said they checked placement for the G-Tube by pushing air and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-17 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to administer medications as ordered. There were 29 opportunities with 3 errors resulting in a 10.34% error rate. This applies to 2 of 10 residents observed in the medication pass. The findings include: 1. On January 15, 2025 at 8:19 AM, during the observation of medication administration, V8 (RN/Registered Nurse) prepared R205's medications. R205 had Amoxicillin-Pot Clavulanate Tablet 875-125 MG (Milligrams) and crushed the medication. V8 also took a PreserVision eye vitamin AREDS (Age-Related Macular Degeneration) 2 soft gel and crushed the soft gel. On January 16, 2025 at 9:26 AM, V8 said the Amoxicillin Clavulanate could be crushed. V8 said if the medication had potassium in it, she should have melted it. V8 said PreserVision also needed to be melted, and she should have put it on hold instead of administering the medication. R205's face sheet showed she was admitted to the facility on [DATE] with diagnoses including injury of left…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-16 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide mechanical soft chili and pureed carrot cake for residents with modified diet consistencies. This applies to 8 of 8 residents (R13, R19, R30, R40, R42, R51, R66, R72) observed during dining in the sample of 21. The findings include: 1. On February 13, 2024 at 11:59 PM, during tray line service on the 4th floor, it was noted residents on Regular and Mechanical Soft diets received the same Chili. The Chili was noted to have whole red kidney beans and varying textures of ground meat. The Fall/Winter menu spreadsheet extension for Tuesday, Week 3 showed to serve ground chunky beef chili for mechanical soft diets. On February 13, 2024 at 12:20 PM, R66 was in the dining room with a diet card showed mechanical soft, nectar thick liquid. V10 (Dietary Assistant) who was in the area stated R66 should receive mechanical soft chili. R66 received regular consistency chili with sour cream along with mashed potatoes, creamed corn and nectar thick…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-16 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to follow standard infection control practices related to hand hygiene and gloving during medication administration and provisions of peri-care. This applies to 4 of 5 residents (R16, R45, R60, R203) reviewed for infection control in the sample of 21. The findings include: 1. On February 14, 2024 at 9:20 AM, V22 (Nurse) administered medications to R16 via gastrostomy tube (g-tube). V22 performed multiple tasks from medication preparation, to getting water from the bathroom faucet, to checking placement of g-tube, and administration of medication via g-tube while wearing the same gloves. After administration of the medications to R16, V22 removed her gloves and left the room without hand hygiene and proceeded to approach another resident (R45) to administer medications. 2. On February 14, 2024 at 9:35 AM, V22 (Nurse) administered medications to R45 via g-tube. V22 put on her gloves without hand hygiene. V22 did multiple tasks from medication preparation, to getting water from the bathroom faucet, to checking…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-16 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide perineal and catheter care in a manner that would prevent urinary tract infection (UTI). This applies to 2 of 3 residents (R45 and R203) reviewed for perineal and indwelling urinary catheter care in the sample of 21. The findings include: 1. R45 had indwelling urinary catheter. On February 14, 2024 at 1:22 PM, V20 and V21 (Both Certified Nursing Assistants/CNA) rendered incontinence care to R45 who had a bowel movement. V20 used wet wipes to clean R45 from front to back of the perineum. However, V20 did not separate the labia to clean the inner corners of the labia, the urethra, and the catheter tubing from the urethra down. 2. On February 14, 2024 at 2:16 PM, V21 (CNA) assisted R203 to use the bedside commode. R203 urinated and had a bowel movement. After R203 used the commode, V21 wiped R203 by reaching the resident's mid perineal area towards the back area. V21 then applied barrier cream and pulled the disposable brief without wiping/cleaning R203's frontal perineum. On February 15, 2024 at 5:06…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-16 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure that the PICC (Peripherally Inserted Central Catheter) line insertion site was visible, so that it could be monitored for signs and symptoms of infection. This applies to 1 of 3 residents (R303) reviewed for intravenous therapy in the total sample of 21. The findings include: On February 13, 2024 at 11:13am, R303 was in bed with PICC in left arm antecubital area. A two-inch square gauze pad covered where the catheter was inserted and the site could not be visualized. The dressing was labeled with the date 2/9/24 and was not signed. The facility record shows R303 was receiving intravenous antibiotic therapy. On February 14, 2024 at 1:05pm, R303 continued to have the PICC, and the dressing remained with the gauze pad folded under the clear occlusive dressing and dated 2/9/24. On February 15, 2024 at 10:56am, V3 (Director of Nurses) viewed the dressing on the PICC on the left arm of R303. V3 stated, I see, that is incorrect. V3 stated there should not be a gauze pad under the clear occlusive dressing. V3…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-16 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to follow physician's order for the administration of oxygen, and failed to ensure the oxygen nasal cannula tubing and humidifier bottle were labeled per policy and procedure. This applies to 1 of 1 resident (R153) reviewed for oxygen use in the sample of 21. The findings include: R153 had multiple diagnoses including pulmonary fibrosis, acute respiratory failure with hypoxia and dependence on supplemental oxygen, based on the face sheet. On February 13, 2024 at 12:42 PM, R153 was in bed, alert and verbally responsive. R153 had ongoing oxygen at 5 (five) liters per minute via nasal cannula using an oxygen concentrator. R153 had no shortness of breath. The humidifier bottle attached to the oxygen concentration and the nasal cannula had no label to indicate when it was changed. On February 14, 2024 at 1:51 PM, R153 was in bed, alert and verbally responsive. R153 stated she was going to sleep. R153 had a breathing mask on while the BiPAP (Bi-level positive airway pressure) machine was connected to the oxygen…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$13,780 in federal fines across 1 penalty.
- $13,780 — penalty dated 2025-01-17
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to LIFESPACE COMMUNITIES — 15 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 4.4 | +0.6 vs chain |
| Health inspection | 4 of 5 | 3.7 | +0.3 vs chain |
| Staffing | 5 of 5 | 4.3 | +0.7 vs chain |
| Quality measures | 5 of 5 | 4.5 | +0.5 vs chain |
The other 14 homes this chain runs (chain average 4.4★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| LIFESPACE COMMUNITIES INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 01/30/2018 |
| KARL, COURTNEY | Individual | W-2 MANAGING EMPLOYEE | — | since 04/04/2022 |
| BLACKFORD, GARY | Individual | CORPORATE DIRECTOR | — | since 12/01/2021 |
| DARKEY-HRINYA, JOYCE | Individual | CORPORATE DIRECTOR | — | since 01/29/2018 |
| DUTRA, ANA | Individual | CORPORATE DIRECTOR | — | since 01/29/2018 |
| FIELDS, VENITA | Individual | CORPORATE DIRECTOR | — | since 01/29/2018 |
| JENSEN, CLAUS | Individual | CORPORATE DIRECTOR | — | since 04/26/2023 |
| MCDONOUGH, AMY | Individual | CORPORATE DIRECTOR | — | since 04/26/2023 |
| SALAMINO, JENIFER | Individual | CORPORATE DIRECTOR | — | since 04/26/2023 |
| SOKEYE, JONATHAN | Individual | CORPORATE DIRECTOR | — | since 12/01/2021 |
| SPANGLER, PATRICK | Individual | CORPORATE DIRECTOR | — | since 01/29/2018 |
| STRETCH, CLYDE | Individual | CORPORATE DIRECTOR | — | since 04/26/2023 |
| WILLIAMS, DAVID | Individual | CORPORATE DIRECTOR | — | since 12/01/2021 |
| YANOFSKY, NEAL | Individual | CORPORATE DIRECTOR | — | since 01/29/2018 |
| GORMAN, JOSEPH | Individual | CORPORATE OFFICER | — | since 07/26/2022 |
| HARSHFIELD, NICHOLAS | Individual | CORPORATE OFFICER | — | since 07/01/2020 |
| JANTZEN, JESSE | Individual | CORPORATE OFFICER | — | since 04/01/2020 |
| KRESSE, NIKKI | Individual | CORPORATE OFFICER | — | since 04/19/2021 |
| POPE, ERIN | Individual | CORPORATE OFFICER | — | since 07/25/2022 |
CMS files one row per role, so the 20 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $3.1M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Illinois Medicaid page for homes that do.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145804. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-20, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.