Cycle 1
Health 2025-01-17 · Fire 2025-01-17
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Downers Grove, IL
Oak Trace
5-star overall rating with 4-star inspections with $13,780 in total fines with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
250 Village Drive, Downers Grove, IL
(630) 769-6200
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
104
Certified beds
Average residents
101
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lifespace Communities
Operator or chain grouping
Approved since
1994-09-01
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
16 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.51
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.14
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.55
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.19
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.64
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.67
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
1.26
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.49
CMS adjusted RN staffing hours
Adjusted total hours
4.13
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
28%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,526
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.38
Composite VBP score used to determine payment impact.
Payment multiplier
0.9831
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.58
Baseline 19.55% · Performance 21.16% · Measure score 0.58 · Achievement 0.58 · Improvement 0
Healthcare-associated infections
0
Baseline 7.35% · Performance 7.93% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.05
Baseline 50.00% · Performance 47.11% · Measure score 4.05 · Achievement 4.05 · Improvement 0.65
Adjusted total nurse staffing
4.72
Baseline 5.11 hours · Performance 4.42 hours · Measure score 4.72 · Achievement 4.72 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.28% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 618 · Observed rate 11.65% · Lower 95% interval 9.59% |
| Discharge to community | 64.61% |
50.57%
14 pts better
|
Better than the National Rate · Eligible stays 634 · Observed rate 56.94% · Lower 95% interval 60.04% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.89% |
95.27%
3.6 pts better
|
Numerator 355 · Denominator 359 |
| Falls with major injury | 0.28% |
0.77%
0.5 pts better
|
Numerator 1 · Denominator 359 |
| Discharge self-care score | 83.51% |
53.69%
29.8 pts better
|
Numerator 233 · Denominator 279 |
| Discharge mobility score | 60.93% |
50.94%
10 pts better
|
Numerator 170 · Denominator 279 |
| Pressure ulcers or injuries, new or worsened | 2.23% |
2.29%
0.1 pts better
|
Numerator 8 · Denominator 359 · Adjusted rate 2.38% |
| Healthcare-associated infections requiring hospitalization | 7.93% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 403 · Observed rate 7.94% · Lower 95% interval 5.69% |
| Staff COVID-19 vaccination coverage | 100% |
8.2%
91.8 pts better
|
Numerator 291 · Denominator 291 |
| Staff flu vaccination coverage | 98.49% |
42%
56.5 pts better
|
Numerator 196 · Denominator 199 |
| Discharge function score | 63.08% |
56.45%
6.6 pts better
|
Numerator 176 · Denominator 279 |
| Transfer of health information to provider | 98.8% |
95.95%
2.8 pts better
|
Numerator 82 · Denominator 83 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 223 · Denominator 223 |
| Resident COVID-19 vaccinations up to date | 61.78% |
25.2%
36.6 pts better
|
Numerator 97 · Denominator 157 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.0
0.1 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.5 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
2.3
1.5 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
89.6%
8.8 pts better
|
93.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.9% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 98.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
91.6%
8.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.5% |
3.3%
0.2 pts worse
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 1.5% · Q3 4.8% · Q4 3.3% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
50.3%
49.1 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.6% · Q3 1.7% · Q4 0.0% · 4Q avg 1.2% |
| Percentage of long-stay residents who lose too much weight | 10.0% |
6.5%
3.5 pts worse
|
5.4%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 12.5% · Q3 6.7% · Q4 11.6% · 4Q avg 10.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 2.2% |
18.5%
16.3 pts better
|
19.6%
17.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 6.2% · Q3 0.0% · Q4 0.0% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.5% |
22.8%
15.3 pts better
|
16.7%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 8.3% · Q3 10.0% · Q4 8.1% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 25.6% |
17.2%
8.4 pts worse
|
16.3%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.8% |
15.0%
3.2 pts better
|
14.9%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 8.7% · Q3 11.6% · Q4 7.5% · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
1.1%
0.3 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.7%
1.3 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.3% |
21.3%
6 pts better
|
19.8%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 13.2% · Q3 15.0% · Q4 6.7% · 4Q avg 15.3% |
| Percentage of long-stay residents with pressure ulcers | 6.9% |
5.2%
1.7 pts worse
|
5.1%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 6.0% · Q3 2.6% · Q4 2.2% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.1% |
68.8%
24.3 pts better
|
81.7%
11.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.0% · Q2 95.1% · Q3 94.5% · Q4 95.0% · 4Q avg 93.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.3% |
14.0%
3.7 pts better
|
12.0%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.3% · Observed 9.4% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
2.3%
1.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.9% |
63.0%
26.9 pts better
|
79.7%
10.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.2% |
26.2%
3 pts better
|
23.9%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.2% · Observed 21.3% · Expected 21.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-16 · Fire 2024-02-16
6 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2023-03-10 · Fire 2023-03-10
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-17
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-01-30
E · Potential for more than minimal harm
2025-01-17
K222 · Egress Deficiencies
Fire Safety
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 2025-01-29
E · Potential for more than minimal harm
2025-01-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-29
F · Potential for more than minimal harm
2024-02-16
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-03-06
F · Potential for more than minimal harm
2024-02-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-06
F · Potential for more than minimal harm
2024-02-16
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-03-07
F · Potential for more than minimal harm
2024-02-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-02-16
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-03-01
E · Potential for more than minimal harm
2024-02-16
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-02-22
E · Potential for more than minimal harm
2024-02-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-05
F · Potential for more than minimal harm
2023-03-10
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-04-03
F · Potential for more than minimal harm
2023-03-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-24
F · Potential for more than minimal harm
2023-03-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-03
E · Potential for more than minimal harm
2023-03-10
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-03-28
Inspection history
Recent health citations
G · Actual harm
2025-01-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-02-03
F · Potential for more than minimal harm
2025-01-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-03
E · Potential for more than minimal harm
2025-01-17
F625 · Resident Rights Deficiencies
Health
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 2025-02-03
E · Potential for more than minimal harm
2025-01-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-17
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-17
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-17
F693 · Quality of Life and Care Deficiencies
Health
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 2025-02-03
D · Potential for more than minimal harm
2025-01-17
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-02-03
G · Actual harm
2024-05-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-04
E · Potential for more than minimal harm
2024-02-16
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-03-08
E · Potential for more than minimal harm
2024-02-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-16
F690 · Quality of Life and Care Deficiencies
Health
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 2024-03-08
D · Potential for more than minimal harm
2024-02-16
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-08
D · Potential for more than minimal harm
2023-06-28
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-07-10
F · Potential for more than minimal harm
2023-03-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-03-20
Penalties and ownership
What sits behind the stars
$13,780
2025-01-17
Fine
Fine · fine $13,780
Fine
Ownership
Lifespace Communities Inc
5% Or Greater Direct Ownership Interest · Organization
Blackford, Gary
Corporate Director · Individual
Darkey-Hrinya, Joyce
Corporate Director · Individual
Dutra, Ana
Corporate Director · Individual
Fields, Venita
Corporate Director · Individual
Gorman, Joseph
Corporate Officer · Individual
Harshfield, Nicholas
Corporate Officer · Individual
Jantzen, Jesse
Corporate Officer · Individual
Jensen, Claus
Corporate Director · Individual
Karl, Courtney
W-2 Managing Employee · Individual
Kresse, Nikki
Corporate Officer · Individual
Lifespace Communities Inc
Operational/Managerial Control · Organization
Mcdonough, Amy
Corporate Director · Individual
Pope, Erin
Corporate Officer · Individual
Salamino, Jenifer
Corporate Director · Individual
Sokeye, Jonathan
Corporate Director · Individual
Spangler, Patrick
Corporate Director · Individual
Stretch, Clyde
Corporate Director · Individual
Williams, David
Corporate Director · Individual
Yanofsky, Neal
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Bria Of Westmont
Westmont, IL
1-star overall rating with 1-star inspections with $151,077 in total fines with 23 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#2
Burgess Square Healthcare Ctr
Westmont, IL
5-star overall rating with 4-star inspections with 10 recent health deficiencies
#3
Chateau Nrsg & Rehab Center
Willowbrook, IL
1-star overall rating with 3-star inspections with $10,358 in total fines with 9 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
Jump out