Oak Trace

Penalties

• Jan 17, 2025 — Fine ($13,780)
• Jan 17, 2025 — IDPH fine (Nursing Home Care Act) ($2,200)
• Jan 17, 2025 — IDPH fine (Nursing Home Care Act) ($500)
• Jan 17, 2025 — IDPH fine (Nursing Home Care Act) ($500)
• May 20, 2024 — IDPH fine (Nursing Home Care Act) ($25,000)

Inspection findings

1. Mar 20, 2026 Health · 6 findings
   • Not serious Scope/severity E

     F0761 Pharmacy Service Deficiencies

     Ensure 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.

     Corrected Mar 25, 2026 · CMS health inspection

   • Not serious Scope/severity E

     K0161 Construction Deficiencies

     Use approved construction type or materials.

     Corrected Apr 20, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0225 Egress Deficiencies

     Have stairways and smokeproof enclosures used as exits that meet safety requirements.

     Corrected Apr 8, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Apr 8, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0754 Miscellaneous Deficiencies

     Provide properly sized and located linen or trash receptacles.

     Corrected Apr 8, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Apr 22, 2026 · CMS fire safety

2. Jan 17, 2025 Health · 15 findings
   • Not serious Scope/severity D

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Feb 3, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0553 Resident Rights Deficiencies

     Allow resident to participate in the development and implementation of his or her person-centered plan of care.

     Corrected Feb 3, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0625 Resident Rights Deficiencies

     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.

     Corrected Feb 3, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Feb 3, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Feb 3, 2025 · CMS health inspection

   • Serious Scope/severity G

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Feb 3, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0693 Quality of Life and Care Deficiencies

     Ensure 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.

     Corrected Feb 3, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Feb 3, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Feb 3, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected Jan 29, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0291 Egress Deficiencies

     Install emergency lighting that can last at least 1 1/2 hours.

     Corrected Jan 30, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Jan 29, 2025 · CMS fire safety

   • Not serious Scope/severity B

     Type B Illinois Nursing Home Care Act violation

     Type B: more likely than not to cause more than minimal harm (1-130). Sections of the Illinois Administrative Code cited: 300.610a), 300.1210b), 300.1210c), 300.1210d)3), and 300.1220b)3). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation: 300.1210b).

     Statement of deficiencies (PDF)

   • Not serious Scope/severity C

     Type C Illinois Nursing Home Care Act violation

     Type C: less than minimal harm (1-132). Sections of the Illinois Administrative Code cited: 300.615e) and 300.615f). This instance in accordance with 300.282f) and j) of the Code is assessed a fine due to the violation of the sections of the Code with a high-risk designation: 300.615e) and 300.615f).

     Statement of deficiencies (PDF)

   • Not serious Scope/severity C

     Type C Illinois Nursing Home Care Act violation

     Type C: less than minimal harm (1-132). Sections of the Illinois Administrative Code cited: 300.661. This instance in accordance with 300.282f) and j) of the Code is assessed a fine due to the violation of the sections of the Code with a high-risk designation: 300.661.

     Statement of deficiencies (PDF)

3. May 20, 2024 Health · 2 findings
   • Serious Scope/severity G Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jun 4, 2024 · CMS health inspection

   • Serious Scope/severity A

     Type A Illinois Nursing Home Care Act violation

     Type A: substantial probability of death or serious harm, or actual harm (1-129). Sections of the Illinois Administrative Code cited: 300.610a), 300.1210b), 300.1210c), and 300.1210d)6). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation: 300.1210b) and300.1210d)6).

     Statement of deficiencies (PDF)

4. Feb 16, 2024 Health · 12 findings
   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected Mar 8, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0694 Quality of Life and Care Deficiencies

     Provide for the safe, appropriate administration of IV fluids for a resident when needed.

     Corrected Mar 8, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Mar 8, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0805 Nutrition and Dietary Deficiencies

     Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

     Corrected Mar 8, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Mar 8, 2024 · CMS health inspection

   • Not serious Scope/severity F

     K0161 Construction Deficiencies

     Use approved construction type or materials.

     Corrected Mar 6, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0225 Egress Deficiencies

     Have stairways and smokeproof enclosures used as exits that meet safety requirements.

     Corrected Mar 1, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Mar 6, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Feb 22, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0916 Gas, Vacuum, and Electrical Systems Deficiencies

     Have a battery powered remote alarm panel in a location accessible by operating personnel.

     Corrected Mar 7, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Mar 22, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Mar 5, 2024 · CMS fire safety

Owners and managers (as published by CMS)

• BLACKFORD, GARY — corporate director, NOT APPLICABLE, since 12/01/2021
• DARKEY-HRINYA, JOYCE — corporate director, NOT APPLICABLE, since 01/29/2018
• DUTRA, ANA — corporate director, NOT APPLICABLE, since 01/29/2018
• FIELDS, VENITA — corporate director, NOT APPLICABLE, since 01/29/2018
• GORMAN, JOSEPH — corporate officer, NOT APPLICABLE, since 07/26/2022
• HARSHFIELD, NICHOLAS — corporate officer, NOT APPLICABLE, since 07/01/2020
• JANTZEN, JESSE — corporate officer, NOT APPLICABLE, since 04/01/2020
• JENSEN, CLAUS — corporate director, NOT APPLICABLE, since 04/26/2023
• KARL, COURTNEY — w-2 managing employee, NOT APPLICABLE, since 04/04/2022
• KRESSE, NIKKI — corporate officer, NOT APPLICABLE, since 04/19/2021
• MCDONOUGH, AMY — corporate director, NOT APPLICABLE, since 04/26/2023
• POPE, ERIN — corporate officer, NOT APPLICABLE, since 07/25/2022
• SALAMINO, JENIFER — corporate director, NOT APPLICABLE, since 04/26/2023
• SOKEYE, JONATHAN — corporate director, NOT APPLICABLE, since 12/01/2021
• SPANGLER, PATRICK — corporate director, NOT APPLICABLE, since 01/29/2018
• STRETCH, CLYDE — corporate director, NOT APPLICABLE, since 04/26/2023
• WILLIAMS, DAVID — corporate director, NOT APPLICABLE, since 12/01/2021
• YANOFSKY, NEAL — corporate director, NOT APPLICABLE, since 01/29/2018
• LIFESPACE COMMUNITIES INC — 5% or greater direct ownership interest, 100%, since 01/30/2018
• LIFESPACE COMMUNITIES INC — operational/managerial control, NOT APPLICABLE, since 01/30/2018