Oak Trace
250 Village Drive, Downers Grove, IL 60516 · Du Page County · 104 certified beds · avg 101 residents/day · certified since Sep 1, 1994
Part of chain: LIFESPACE COMMUNITIES (15 facilities, chain avg rating 4.4★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · CMS overall rating: 5/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Jan 17, 2025 · F-0692
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Feb 3, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 20, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 4, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (16)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Mar 20, 2026 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jan 17, 2025 | ▲ G · Actual harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Jan 17, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jan 17, 2025 | E · Potential for harm, repeated | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Jan 17, 2025 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jan 17, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jan 17, 2025 | D · Potential for harm, one-off | The facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences. |
| Jan 17, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jan 17, 2025 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Jan 17, 2025 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| May 20, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Feb 16, 2024 | E · Potential for harm, repeated | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
| Feb 16, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 16, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Feb 16, 2024 | D · Potential for harm, one-off | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. |
| Feb 16, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (9 → 1).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 6 | 1 | G ▲ |
| 2025 | 9 | 1 | G ▲ |
| 2026 | 1 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $13,780.
| Date | Type | Amount / length |
|---|---|---|
| Jan 17, 2025 | Fine | $13,780 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Illinois avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.41 | 2.99 | 3.95 | top 12% in Illinois; top 25% in the U.S. |
| Registered Nurse hours | 1.61 | 0.63 | 0.69 | top 5% in Illinois; top 4% in the U.S. |
| Weekend total nurse staffing | 3.95 | 2.67 | 3.50 | top 12% in Illinois; top 24% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 1.37 | 0.56 | 0.48 | top 4% in Illinois; top 2% in the U.S. |
| Total nursing staff turnover (%) | 39.3 | 44.5 | 45.8 | top 36% in Illinois; top 35% in the U.S. |
| RN turnover (%) | 17.1 | 41.8 | 42.9 | top 13% in Illinois; top 11% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.30, RN 1.57, weekend 3.84. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Lifespace Communities INC | Organization | 5% or Greater Direct Ownership Interest | 100% | 01/30/2018 |
| Blackford, Gary | Individual | Corporate Director | NOT APPLICABLE | 12/01/2021 |
| Darkey-Hrinya, Joyce | Individual | Corporate Director | NOT APPLICABLE | 01/29/2018 |
| Dutra, Ana | Individual | Corporate Director | NOT APPLICABLE | 01/29/2018 |
| Fields, Venita | Individual | Corporate Director | NOT APPLICABLE | 01/29/2018 |
| Gorman, Joseph | Individual | Corporate Officer | NOT APPLICABLE | 07/26/2022 |
| Harshfield, Nicholas | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2020 |
| Jantzen, Jesse | Individual | Corporate Officer | NOT APPLICABLE | 04/01/2020 |
| Jensen, Claus | Individual | Corporate Director | NOT APPLICABLE | 04/26/2023 |
| Karl, Courtney | Individual | W-2 Managing Employee | NOT APPLICABLE | 04/04/2022 |
| Kresse, Nikki | Individual | Corporate Officer | NOT APPLICABLE | 04/19/2021 |
| Lifespace Communities INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/30/2018 |
| McDonough, Amy | Individual | Corporate Director | NOT APPLICABLE | 04/26/2023 |
| Pope, Erin | Individual | Corporate Officer | NOT APPLICABLE | 07/25/2022 |
| Salamino, Jenifer | Individual | Corporate Director | NOT APPLICABLE | 04/26/2023 |
| Sokeye, Jonathan | Individual | Corporate Director | NOT APPLICABLE | 12/01/2021 |
| Spangler, Patrick | Individual | Corporate Director | NOT APPLICABLE | 01/29/2018 |
| Stretch, Clyde | Individual | Corporate Director | NOT APPLICABLE | 04/26/2023 |
| Williams, David | Individual | Corporate Director | NOT APPLICABLE | 12/01/2021 |
| Yanofsky, Neal | Individual | Corporate Director | NOT APPLICABLE | 01/29/2018 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "If my family member goes to the hospital, how long will you hold their bed, and will we get that in writing?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "How are residents and families included in care plan meetings, and how often do those meetings happen?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Bria of Westmont | 1.0 mi | Westmont, IL | ★☆☆☆☆ | 1/5 | |
| Burgess Square Healthcare Ctr | 1.4 mi | Westmont, IL | ★★★★☆ | 3/5 | |
| Chateau Nrsg & Rehab Center | 3.0 mi | Willowbrook, IL | ★★☆☆☆ | 3/5 | |
| Eden Vista Burr Ridge | 3.2 mi | Burr Ridge, IL | ★★★★☆ | 4/5 | |
| Oakwood Rehab and Nursing Center | 3.5 mi | Westmont, IL | ★☆☆☆☆ | 1/5 | abuse |
| Pearl of Hinsdale, the | 4.1 mi | Hinsdale, IL | ★★★★☆ | 4/5 | |
| The Pearl of Downers Grove | 4.2 mi | Downers Grove, IL | ★☆☆☆☆ | 2/5 | |
| The Commons at Lisle Creek Estates | 5.1 mi | Lisle, IL | ★★★★☆ | 4/5 | |
| Briar Place Nursing | 5.2 mi | Indian Head Park, IL | ★☆☆☆☆ | 2/5 | abuse |
| Beacon Hill | 5.4 mi | Lombard, IL | ★★★★★ | 4/5 | |
| Alta Rehab at Oak Brook | 5.7 mi | Oak Brook, IL | ★★☆☆☆ | 2/5 | |
| Bella Terra Lombard | 5.8 mi | Lombard, IL | ★★★★☆ | 3/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 145804.