Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Landmark Of Oak Lawn Rehabilitation And Nursing Ce during CMS and state inspections, most recent first.
Surveyors found that staff did not provide timely incontinence care to three dependent residents, despite care plans and facility guidelines requiring at least every two-hour checks and peri-care after incontinent episodes. One resident with mild cognitive impairment was repeatedly left in a soiled brief until late morning on consecutive days, with CNAs citing tray service duties and being pulled from other floors as reasons for delay. Another resident with severe cognitive impairment was reportedly not checked for several hours, during which time her brief became heavily soiled with bowel movement before being changed. A cognitively intact resident dependent on toileting hygiene waited in a moderately wet, brownish brief until she used the call light, after which a CNA, newly reassigned to that floor and unaware of her assignment, responded and provided care.
A resident with paraplegia, diabetes, pancreatic cancer, and multiple stage 3–4 pressure ulcers was found with sacral and left ischial dressings that were soiled, dirty, peeling, and dated two days earlier, indicating that daily wound care had not been provided as ordered. When an LPN performed wound care, the wounds were cleansed with saline and treated with medi honey and calcium alginate instead of the physician-ordered debriding product and silicone super absorbent dressing, with the LPN stating the ordered product could not be found. The wound care physician later confirmed that the specific product had been ordered to debride dead tissue and was to be used for the resident’s chronic wounds.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors.
Several dependent residents with significant self-care deficits did not receive proper assistance with ADLs, including bathing, grooming, and nail care. Observations included uncombed hair, soiled feet, full beards, and long fingernails, with staff either unaware of care schedules or assuming tasks were completed by others. Care plans documented the need for extensive support, but required hygiene and grooming were not consistently provided.
A resident who is totally dependent on staff for all ADLs was unable to access their bedroom shower for over a month due to a broken door, and staff did not provide showering assistance in the resident's preferred location. The DON was unaware of the maintenance issue, and the resident was not assisted with bathing unless they agreed to use a shower on another floor, which they refused.
A resident with multiple chronic conditions was found with an unlabeled inhaler at bedside without timely completion of the required self-administration assessment. Staff interviews revealed inconsistent adherence to policy regarding medication storage and assessment, and the inhaler was not kept in pharmacy-provided packaging as required. The necessary interdisciplinary assessment and documentation were not completed as scheduled.
Two residents with dementia and self-care deficits were observed in the dining area and hallway without proper footwear, despite care plans requiring staff assistance to ensure appropriate shoes and socks. Staff acknowledged the oversight, and in one case, a resident's shoes were found stored in a closet bag, possibly by a family member. The DON confirmed the expectation for all residents to have proper footwear in accordance with facility policy.
A resident with multiple chronic conditions was permitted to self-administer an inhaler per physician order, but the facility did not initiate or update the care plan to reflect this change as required by policy. The necessary assessment and care plan for self-medication were not completed until months after the order was given, as confirmed by the Regional Nurse Consultant.
A resident dependent on enteral tube feeding was observed lying with the head of the bed elevated only to 20 degrees during feeding, contrary to physician orders and facility policy requiring a 30-45 degree elevation to prevent aspiration. The DON and a CNA confirmed the correct procedure was not followed, and the resident's medical record indicated multiple diagnoses necessitating strict adherence to feeding protocols.
A resident with COPD and other medical conditions was found with oxygen tubing left uncovered and unlabeled on a bedside drawer when not in use. The DON confirmed the tubing was not stored in a plastic bag or labeled as required by facility policy, which specifies weekly changes and proper documentation.
The facility did not consistently document shift change counts for controlled substances, as required by policy. On review, a medication cart's controlled substance sign-in sheet was found to have missing nurse initials on several dates, and LPNs confirmed that while counts are supposed to be done and signed each shift, this was not always documented. The DON and Administrator were unaware of the missing signatures and provided copies of the sheets with all dates filled in, despite earlier findings of incomplete records.
A resident with multiple chronic conditions was found with an unlabeled inhaler on the bedside table, contrary to facility policy requiring medications to be stored in pharmacy-provided packaging with proper labeling. Although there was a physician order for bedside self-administration, the required assessment was not completed, and the medication was not stored according to infection control and labeling standards, as confirmed by both an LPN and the DON.
The facility did not follow its activity calendar, failing to engage residents in scheduled tabletop games. During a survey, it was observed that no activities were taking place, and four residents were not engaged by staff. The Activity Director confirmed the absence of activities, and two CNAs present were not facilitating any engagement. This indicates a failure to meet the facility's policy of providing therapeutic recreation opportunities.
The facility failed to investigate and identify the origins of injuries for two residents, leading to deficiencies in their abuse prevention policy. One resident with moderate cognitive impairment sustained a wrist fracture and a large bruise, while another with severe cognitive impairment reported a hip fracture after a fall. Despite medical assessments suggesting falls, the facility classified these injuries as of unknown origin, failing to meet investigation requirements.
A resident with hemiplegia and cognitive impairment was left in a soiled and saturated state for over five hours, contrary to the facility's policy of checking and changing every two hours. The resident was found with a strong smell of urine and expressed feeling cold, highlighting a failure in providing timely incontinence care.
A resident with severe cognitive impairment was physically abused by her roommate, resulting in facial injuries. Despite the resident's vulnerability, the facility did not have an abuse care plan in place. The roommate, known for verbal aggression, admitted to hitting the resident. The facility's policies on abuse prevention and care planning were not adequately followed, contributing to the incident.
The facility failed to follow food safety and sanitation policies, including hand hygiene, thermometer cleaning, and use of standardized recipes. Staff did not wash hands when changing gloves, used thermometers without proper cleaning, and did not maintain sanitizing solution concentration. Meals were prepared without recipes, leading to unmeasured seasoning, potentially affecting residents with dietary restrictions.
The facility failed to maintain a medication error rate below 5%, resulting in a 10% error rate. Two residents did not receive their medications as prescribed: one due to missing medications and the other due to late administration. Additionally, a nurse left medication unattended, violating facility policy. The DON confirmed that medications should be administered within a specific time frame and under supervision.
A resident with a history of fractures and other medical conditions fell during incontinence care when only one CNA assisted her, despite needing two-person assistance. This resulted in injuries requiring hospital evaluation. The facility's policy mandates two caregivers for such residents, which was not followed.
A resident accessed a medication cart in an LTC facility due to a failure in securing the cart keys. The incident involved a resident with a history of substance abuse and mental health issues. The keys were left unattended by an LPN, contrary to facility policy, allowing the resident to access the cart. The DON was informed, and the incident was investigated, revealing a breach in medication storage protocols.
The facility failed to maintain safe and comfortable room temperatures, with temperatures exceeding 80°F and humidity above 60%. Residents expressed discomfort, and maintenance issues with air conditioning units were unresolved. The facility did not follow its extreme weather policy, affecting all 47 residents.
A resident with a history of psychosis and anxiety reported being physically abused by a nurse during a forced shower, resulting in bruising and scratches. Despite an investigation involving video review and interviews, the facility could not substantiate the claims or determine the cause of the injuries, highlighting a gap in resident protection and investigation processes.
A resident in a LTC facility reported not receiving a shower since admission and was unaware of her shower schedule. Despite being cognitively intact, she only received bed baths, contrary to her preference for showers using a shower bed. The facility lacked documentation on her bathing care, and the administrator admitted they could not provide shower sheets. This failure violated the resident's rights to dignity and self-determination.
A resident was physically abused by an RN after an altercation over heating food. The RN intervened by moving the resident's hands, leading to a physical fight where both parties hit each other. The resident sustained multiple injuries, including a fractured finger. The incident was not promptly reported, delaying the abuse investigation. The DON believed the injuries occurred outside the facility. The facility's abuse prevention policy was not followed, and there were gaps in staff training and documentation, including missing abuse screens and care plans for the resident.
Failure to Provide Timely Incontinence Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care in accordance with its Guidelines for Incontinence Care and residents’ care plans for three dependent residents. One resident with mild cognitive impairment and documented dependence on toileting hygiene reported in the morning that she thought she was wet; later that morning she was observed wearing a dark, blackish incontinent brief with a strong odor of urine and feces. The CNA assigned stated she had been on duty since 7:00 AM, had been passing meal trays, and had not yet changed the resident. The following day, the same resident reported she had not yet been changed by mid-morning; a CNA then stated she had just been pulled from another floor and had not yet changed the resident. When incontinence care was finally provided, the resident’s brief was moderately wet with urine. The resident’s restorative care plan required checks every two hours and as needed, with perineal cleansing and clothing changes after incontinence episodes. Another resident with severe cognitive impairment and dependence on toileting hygiene was reported by her fiancé to have received no checks between his arrival in the morning and early afternoon. He stated that by early afternoon the resident’s incontinent brief was heavily soaked with bowel movement and was smelly, and that staff changed her at that time. A third resident, cognitively intact but dependent on toileting hygiene, reported waiting to be changed and stated she had last been changed in the early morning by night staff. After the resident activated her call light, a CNA responded and found the resident with a moderately wet, brownish-colored incontinent brief; the CNA stated she had just been moved from another floor, had not received report, and that no nursing assistant had been assigned to that resident. The DON stated that staff are supposed to change incontinent residents every two hours and as needed, and the facility’s undated Guidelines for Incontinence Care require at least every two-hour checks and assistance with cleansing after incontinence episodes, which was not followed in these cases.
Failure to Provide Ordered Wound Care for Chronic Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and its own wound care policy for a resident with multiple chronic pressure ulcers. The resident, an older female with mild cognitive impairment, paraplegia, pancreatic cancer, diabetes, and multiple stage 4 pressure ulcers (left hip, sacral, left ischium, right buttocks) and a stage 3 right heel ulcer, had wound care orders from a wound care physician. The physician ordered a specific product to be applied after cleansing the sacral and left ischium wounds, followed by a silicone super absorbent dressing, to be done daily and as needed. The facility’s policy stated that wound dressing changes are to be performed as ordered by the physician using clean technique on all chronic or contaminated wounds. On observation, CNAs providing incontinence care found the resident’s stage 4 sacral and stage 4 left ischium wounds with soiled, dirty dressings that were peeling off and dated two days prior, indicating that wound care had not been provided the previous day. Later that morning, an LPN performing wound care confirmed that the old dressings were soiled, dirty, peeling, and dated two days earlier, and stated that this indicated no wound care had been done the day before. During the dressing change, the LPN cleansed the wounds with saline, patted them dry, and applied medi honey and calcium alginate instead of the ordered product and silicone super absorbent dressing, explaining that the ordered product could not be found in the treatment cart. The wound care physician later stated that the ordered product was intended to debride dead tissue from the wound bed and that the facility should have used it as ordered.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified based on observations and findings by surveyors, indicating that the environment posed risks for accidents and that supervision measures in place were insufficient to prevent such incidents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Adequate ADL Assistance and Grooming
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for four dependent residents, specifically in the areas of bathing, grooming, and nail care. Observations revealed that one resident was seen with uncombed hair and heavily soiled feet, and staff were unsure when the last shower was provided. Another resident was observed with a full beard, and staff assumed that a family member had performed shaving, while the DON stated that all residents should be groomed daily. A third resident was found in bed with a full beard and long, soiled fingernails; staff believed a hospice aide was responsible for grooming, but the DON clarified that daily assigned CNAs should ensure completion of any unmet care needs. The fourth resident was observed with long, curved fingernails and reported not having received a shower, expressing a preference for nail trimming rather than cutting off nails. All four residents had documented diagnoses such as dementia, Alzheimer’s disease, quadriplegia, and other conditions requiring assistance with personal care. Their care plans indicated a need for extensive support with ADLs, including bathing, dressing, grooming, and personal hygiene. Facility policy requires routine daily care and coordination between residents and caregivers, emphasizing resident preferences. Despite these requirements, the observed lack of grooming and hygiene care demonstrated a failure to meet the established standards for ADL support for these dependent residents.
Failure to Provide Access to Resident's Shower Room Resulting in Lack of Bathing Assistance
Penalty
Summary
A resident with quadriplegia, paraplegia, obesity, and muscle weakness, who is totally dependent on staff for all activities of daily living, was not provided access to a functioning shower in their bedroom for over a month. The resident reported that the shower room door in their bedroom was broken and had not been opened for an extended period, resulting in the resident not receiving a shower during that time. The resident also stated that nursing staff would not assist with showering unless the resident agreed to use a shower room on another floor, which the resident refused. The Director of Nursing confirmed that the resident refused to use the upstairs shower and was unaware of how long the bedroom shower door had been broken or if maintenance had been notified. There was no evidence that the issue had been addressed or that the resident's preference for using their own shower was accommodated. The care plan indicated the resident required total assistance for bathing, but there were no recent shower records, suggesting a lack of bathing assistance during the period the shower was inaccessible.
Failure to Assess and Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for safe self-administration of medication, specifically regarding the use of an inhaler at bedside. During observation, the resident was found with an inhaler on the bedside table that lacked a name or open date, and the resident stated she was allowed to keep it at bedside. Staff interviews revealed inconsistency in the application of facility policy, with a LPN stating that residents are generally not supposed to have medications at bedside unless there is an order, and confirming that she would need to check for such an order. Further review showed that the required self-administration assessment for the resident was not completed on the date it was due, but was instead finalized several months later. The care plan for the resident, who has multiple chronic conditions including multiple sclerosis, COPD, epilepsy, muscle weakness, diabetes, and asthma, was only initiated after the assessment was completed late. Facility policy requires that residents who self-administer medications must be assessed for their ability to do so safely, and that medications kept at bedside must be stored in pharmacy-provided packaging with proper labeling. Staff interviews confirmed that the inhaler was not stored according to these requirements, lacking both the original packaging and necessary labeling. The physician order for the resident did allow for the inhaler to be kept at bedside, but the interdisciplinary team assessment and proper documentation were not completed in a timely manner, resulting in a failure to ensure safe medication self-administration and storage.
Failure to Ensure Residents Wore Proper Footwear in Common Areas
Penalty
Summary
Two residents were observed in common areas of the facility without proper footwear, which is inconsistent with their care plans and facility policy regarding dignity and personal possessions. One resident, diagnosed with dementia and requiring assistance with personal care, was seen exiting the dining area without socks or shoes after having spent the entire morning in the dining room. A CNA acknowledged the resident's lack of footwear and stated she was just beginning to assist the resident with socks and shoes. The Director of Nursing confirmed the expectation that this resident should have shoes and socks on daily, especially since the resident walks the hallway. The resident's care plan specifically included interventions to ensure proper footwear and nonskid socks prior to activities of daily living. Another resident, with diagnoses of Alzheimer’s disease and dementia and also requiring assistance with personal care, was observed sitting in the dining room without shoes. A CNA reported being unable to find the resident's shoes at the start of the shift. Upon searching the resident's room, the shoes were found in a plastic bag on a closet shelf, possibly placed there by the resident's daughter. The Director of Nursing reiterated the expectation that all residents should have socks and shoes on. The care plan for this resident also included interventions to ensure the resident wore appropriate footwear to promote safety and mobility during ambulation, wheelchair use, and transfers.
Failure to Timely Update Care Plan for Self-Medication Administration
Penalty
Summary
The facility failed to update the care plan for a resident who was authorized to self-administer medication. Despite having an active physician order allowing the resident to keep an inhaler at bedside and self-administer Albuterol as needed, no care plan was initiated at the time the order was received. The care plan was only created several months later, after the deficiency was identified. The facility's own policy requires that a care plan be developed and updated when there is a change in medication scheduling, dose, or the resident's condition, and that the interdisciplinary team must approve and document the resident's ability to self-administer medications. The resident involved had multiple complex diagnoses, including multiple sclerosis, COPD, epilepsy, muscle weakness, diabetes, and asthma. The assessment for self-administration of medications was not completed as required, and the care plan addressing the resident's desire and ability to self-administer medication was not initiated until after the deficiency was noted. This lapse was confirmed by the Regional Nurse Consultant, who acknowledged that the care plan should have been started when the self-administration order was received.
Failure to Maintain Proper Bed Elevation During Enteral Feeding
Penalty
Summary
A dependent resident receiving enteral tube feeding was found lying in bed with the head of the bed elevated only to a 20-degree angle while the feeding was infusing. Observation confirmed that the resident was positioned low in the bed, with feet touching the footboard, and the head of the bed was not elevated to the required angle. A CNA acknowledged that the resident should have been positioned with the head of the bed at a 40-degree angle to prevent choking and that it was her responsibility to monitor the resident when the hospice CNA was not present. The CNA then repositioned the resident and adjusted the bed elevation accordingly. The Director of Nursing confirmed that all residents with feeding tubes should have the head of the bed elevated at a 30-40-degree angle and be properly positioned in bed to prevent aspiration. The resident's medical record indicated diagnoses of unspecified protein calorie malnutrition, gastrostomy status, chronic kidney disease, and muscle wasting, with a physician order specifying that the head of the bed should always be elevated at a 45-degree angle during tube feeding, except during activities of daily living. Facility policy also required nurses to maintain the head of the bed at 30-45 degrees during and after tube feeding. These requirements were not followed at the time of observation.
Failure to Properly Store and Label Oxygen Tubing
Penalty
Summary
The facility failed to ensure proper storage, labeling, and timely changing of oxygen tubing for a resident requiring respiratory care. During observation, a resident with diagnoses including COPD, hypertension, tobacco use, and other conditions was found with oxygen tubing left uncovered on top of a bedside drawer when not in use. The resident stated that staff placed the tubing there when it was not needed. The DON confirmed the tubing was uncovered, unlabeled, and not stored in a plastic bag as required by facility policy, which mandates that oxygen tubing be changed at least weekly or as needed, and labeled with the date, time, and staff initials. The resident had an active physician order for oxygen administration due to COPD/asthma exacerbation.
Failure to Document Controlled Substance Shift Change Counts
Penalty
Summary
The facility failed to properly account for controlled substances by not ensuring that the Shift change accountability record was consistently completed. During observations and interviews, it was found that the controlled substance sign-in sheet for one medication cart had missing initials on several dates, indicating that the required signatures from both the incoming and outgoing nurses were not always documented. Licensed Practical Nurses confirmed that while the narcotic count is supposed to be performed and documented at every shift change, there were instances where initials were missing, and it was unclear whether the count had actually been performed on those dates. Further review with the Director of Nursing and the Administrator revealed that they were unaware of the missing initials and expected the narcotic count and sign-in process to be completed every shift. When asked to provide documentation, copies of the sign-in sheets were produced with all dates filled in, despite earlier observations of missing initials. The facility's policy requires that both nurses count and sign for controlled substances at each shift change, but this procedure was not consistently followed as evidenced by the incomplete records.
Improper Storage and Labeling of Bedside Medication
Penalty
Summary
A deficiency was identified when a resident's medication, specifically an inhaler, was found on top of the bedside table without a name or open date visible. The resident stated she was permitted to keep the inhaler at her bedside. Upon inquiry, an LPN confirmed that while some residents are allowed to have medications at bedside, she would need to verify if there was an order for this. Further interviews revealed that all medications should be kept in their original packaging, which includes the resident's name, medication name, instructions, and the date opened, and should be stored in the package for infection control purposes. The DON also stated that medications kept at bedside should remain in pharmacy-provided packaging with proper labeling. The resident involved had multiple diagnoses, including multiple sclerosis, COPD, epilepsy, muscle weakness, diabetes, and asthma, and had an active physician order for an albuterol inhaler to be kept at bedside. However, the self-administration of medications assessment had not been completed at the time of the observation, and the inhaler was not stored according to facility policy or manufacturer/supplier recommendations. Facility policy requires that medications for bedside storage be kept in containers dispensed by the pharmacy, with appropriate labeling and documentation, which was not followed in this instance.
Failure to Engage Residents in Scheduled Activities
Penalty
Summary
The facility failed to adhere to its activity calendar and engage residents in scheduled social activities, specifically tabletop games, on February 25, 2025. During a surveyor's visit to the dining room on the second floor at 11:25 am, it was observed that no activities were taking place, despite the activity calendar indicating that tabletop games were scheduled for 11:00 am. The Activity Director, identified as V6, confirmed the absence of activities and stated that she was responsible for conducting them. Two CNAs, V7 and V8, were present in the dining room but were not engaging residents in any activities. Instead, they were involved in other tasks such as talking to a resident and performing one-to-one monitoring. Four residents, identified as R6, R7, R8, and R9, were observed in the dining room, none of whom were engaged in social activities. R6 and R7 were seen with their heads down on the table, while R8 and R9 were sitting without engagement. The facility's policy emphasizes the importance of providing a variety of therapeutic recreation opportunities to meet the physical, mental, and psycho-social well-being needs of each resident. However, the lack of adherence to the activity schedule and the absence of staff engagement with residents indicate a failure to meet these policy standards.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to adhere to its abuse prevention policy by not adequately investigating and identifying the origins of injuries sustained by two residents, R1 and R2. R1, who had moderate cognitive impairment and muscle weakness, was found with a discoloration on her left arm, which was later diagnosed as an acute wrist fracture. Additionally, R1 had a large bruise on her right flank. Despite R1's inability to explain the injuries, the facility did not determine the cause of these injuries, and staff were unaware of the right flank bruise. Medical professionals suggested that R1's fracture could be associated with a fall, yet the facility classified the injury as of unknown origin. R2, diagnosed with cerebral palsy and severe cognitive impairment, reported pain in her right hip, which was later identified as a fracture. R2 claimed to have fallen while attempting to transfer herself to a wheelchair, but the facility's investigation concluded that there was no recent fall. Despite R2's report and the orthopedic surgeon's assessment that the fracture was consistent with a fall, the facility classified the injury as of unknown origin. The facility's failure to properly investigate and document these incidents resulted in a lack of clarity regarding the cause of R2's injury. The facility's policy on injuries of unknown origin requires a thorough investigation, including reviewing medical records and interviewing witnesses, to determine the cause of such injuries. However, in both cases, the facility did not meet these requirements, leading to a deficiency in protecting residents from potential abuse or neglect. The lack of proper documentation and investigation into the residents' injuries highlights a significant oversight in the facility's adherence to its abuse prevention program.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide appropriate incontinence care for a resident diagnosed with hemiplegia, hemiparesis, functional quadriplegia, and reduced mobility, who requires assistance with personal care. The resident, who has moderate cognitive impairment and is always incontinent of urine, was left soiled and saturated in urine for over five hours. The care plan for the resident indicated the need for appropriate cleansing and peri-care after each incontinent episode, but this was not adhered to. On the day of observation, the resident was found in bed with a strong smell of urine, lying on a wet pad with a large dark brown ring, indicating prolonged exposure to urine. The resident's adult brief was saturated with dark yellow urine, and the resident expressed feeling cold. The CNA responsible for the resident admitted that the last change occurred at 7:30 am, despite the policy requiring checks and changes every two hours. This neglect in care was confirmed by a nurse who observed the same conditions.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from physical abuse, resulting in an incident where one resident hit another in the face. The affected resident, who has a history of dementia and other mental health disorders, was found with discoloration around her left eye and bleeding from her nose and mouth. She was sent to the hospital and diagnosed with a facial hematoma due to physical trauma. Despite the resident's severe cognitive impairment, the facility did not have an abuse care plan in place for her. The incident occurred when the resident was in her room with her roommate, who was identified as the alleged perpetrator. The roommate, who has a history of verbal aggression and had previously requested a room change due to conflicts with peers, was found with blood on her hand and admitted to hitting the resident because she was in her space. Staff members, including a CNA and a restorative aide, witnessed the aftermath of the incident and reported the roommate's aggressive behavior. However, the facility's administrator expressed uncertainty about how the resident sustained her injuries, citing the resident's tendency to wander and her severe cognitive impairment. The facility's policies on abuse prevention and care planning were not adequately followed. The interdisciplinary team did not develop an abuse care plan for the resident, despite her vulnerability and the incident of abuse. The facility's policy requires care plans to be developed for residents with identified problems, but the resident's care plan did not address the risk of abuse. The facility's failure to implement appropriate care planning and monitoring contributed to the resident's exposure to abuse and subsequent injury.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to its food safety and sanitation policies, which resulted in multiple deficiencies during food preparation. Staff members, including V13, did not perform hand hygiene when changing gloves, which is a critical step in preventing cross-contamination. V13 was observed repeatedly removing gloves, discarding them, and putting on new gloves without washing hands in the handwashing sink. This practice was consistent throughout the food preparation process, including when V13 interacted with delivery personnel and handled various food items. Additionally, the facility did not maintain proper sanitation practices with the use of thermometers and sanitizing solutions. V13 used a thermometer to check food temperatures without cleaning it with alcohol wipes before and after use, instead rinsing it with water and wiping it with a wet towel that was not stored in a sanitation bucket. The sanitizing solution in the kitchen was also found to be below the required concentration, indicating a failure to maintain proper sanitation levels. The facility's staff did not follow standardized recipes during food preparation, which is essential for ensuring accurate measurements and adherence to dietary restrictions. V13 prepared meals without using recipes, leading to unmeasured seasoning of food items, which could affect residents with dietary restrictions. The Dietary Manager, V12, confirmed that recipes were available but were not utilized by V13 during the preparation of meals. These failures in following established policies and procedures have the potential to impact all residents receiving meals from the facility's kitchen.
Medication Administration Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 10% error rate during a survey. This deficiency was observed during medication administration for two residents. One resident, with diagnoses including anemia and benign prostatic hyperplasia, did not receive their prescribed medications, Cyanocobalamin and Finasteride, because the medications were missing from the cart. Another resident, with conditions such as anemia and gastric-esophageal reflux disease, received their Pantoprazole Sodium medication late, outside the facility's allowed time frame. Additionally, during the administration of medication to the second resident, the nurse left the medication unattended on a table while retrieving a straw, which is against the facility's policy that requires medications to be under the nurse's supervision at all times. The Director of Nursing confirmed that medications should be administered within one hour before or after the scheduled time and that any deviations should be reported to a physician or in-house nurse practitioner. The facility's policy also mandates that nurses ensure residents swallow their medications, which was not adhered to in this instance.
Failure to Provide Adequate Assistance During Incontinence Care
Penalty
Summary
The facility failed to prevent an accident involving a resident who required two staff members for assistance during incontinence care. The resident, a female with a history of multiple medical conditions including a left peri-prosthetic hip fracture and osteoporosis, experienced a fall while being assisted by only one staff member. This incident resulted in the resident sustaining a left forehead hematoma, a skin tear on the right forearm, and a fracture of the left fifth metacarpal, necessitating an emergency hospital transfer. The incident occurred when the resident rolled out of bed during incontinence care provided by a single Certified Nursing Assistant (CNA), despite the resident's care plan indicating the need for two-person assistance. The CNA admitted to providing care alone, which led to the resident rolling out of bed and hitting her face on an oxygen concentrator. The resident was subsequently assessed by an Agency Registered Nurse, who confirmed the need for two-person assistance due to the resident's dependency and size. The Director of Nursing and the facility's Administrator acknowledged that the CNA should have followed the care plan and requested assistance. The facility's policy on incontinence care requires two caregivers to assist residents who are dependent, as outlined in the Minimal Data Set assessment. The failure to adhere to this policy directly contributed to the resident's fall and subsequent injuries.
Medication Storage Breach in LTC Facility
Penalty
Summary
The facility failed to ensure that medications were stored safely and securely, as required by their policy. This deficiency was identified when a resident, referred to as R4, accessed the medication cart. On the night shift of 10/20/24, a Registered Nurse (RN), V8, reported receiving information from a Licensed Practical Nurse (LPN), V11, that R4 had gotten into the medication cart. A Certified Nursing Assistant (CNA), V2, witnessed R4 with the nurse's keys in her hands and observed her putting the keys back in the binder on the nurse's cart. V2 reported this to the nurse, who was attending to another resident at the time. The Director of Nursing (DON), V5, was informed of the incident on 10/21/24 by a manager. V5 investigated by speaking with V12, who reported the incident, and attempted to contact V11, who was unavailable. V5 learned that V11 had left the keys in a drawer during wound care for another resident, contrary to the facility's policy that requires nurses to keep the medication cart keys on them at all times. The facility's policy also mandates that medication carts and supplies be locked or attended by authorized personnel. R4 had a history of substance abuse and mental health issues, including a past suicide attempt by taking pain pills. R4's care plan noted socially inappropriate behavior and non-compliance with safe smoking regulations. Despite these concerns, there were no progress notes related to R4 being seen with the medication cart keys from 10/18/24 to 10/22/24. R4 was eventually discharged to another facility on 10/22/24. The facility's failure to secure the medication cart allowed R4 to access it, which was a breach of their medication storage policy.
Failure to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe and comfortable environment for its residents, as evidenced by room temperatures exceeding 80 degrees Fahrenheit and humidity levels above 60%. This issue was observed in multiple resident rooms, despite the central air conditioning and portable fans being operational. The facility did not identify all residents at high risk for heat stroke or heat exhaustion, nor did it follow its extreme weather conditions policy to monitor ambient temperatures effectively. This failure affected all 47 residents in the facility. Observations and interviews revealed that residents and their family members expressed discomfort due to the high temperatures. Some residents reported that their air conditioning units were not functioning properly, and maintenance logs indicated unresolved issues with these units. Additionally, residents were not consistently provided with cold drinks or ice water, and some were not assisted into cooler areas of the facility. The facility's maintenance staff was not present for a period, and there was a lack of documentation regarding the monitoring of room temperatures and resident conditions. The facility's contracted HVAC service provider identified significant maintenance issues, including nonfunctional compressors and clogged convectors in resident rooms. The facility's maintenance records showed a lack of preventive maintenance, contributing to the inadequate cooling. The facility's policies required monitoring of ambient temperatures and resident conditions during extreme weather, but these were not followed, leading to the deficiency.
Removal Plan
- Facility Administrator initiated additional monitoring of air temperatures, taking and tracking air temperatures every 2 hours. This is still currently in place and will be continued until all room temperatures are consistently at 75 degrees or below; at which time daily monitoring of temperatures will resume in accordance with facility standard procedures.
- Facility Administrator assigned department managers to assist direct care staff with monitoring residents every 2 hours and questioning residents about comfort. Residents in rooms with the highest recorded temperatures were also asked/encouraged to move to another/cooler room.
- Facility Administrator provided residents with fans as available.
- Facility Activity personnel passed out popsicles to residents, in accordance with prescribed diets.
- Facility Administrator instructed licensed nurses and C.N.A.s to increase monitoring of all residents and increase the provision of ice/water. Administrator also encouraged staff to encourage mobile residents' use of hydration stations provided on both floors.
- Facility DON implemented additional temperature (vital) monitoring (2 times/shift) for all residents.
- Facility Nursing Managers identified residents with higher risk for negative effects related to hot temperatures. Residents with mobility, respiratory, g-tube dependent, and other concerns outlined in the facility's Extreme Weather policy were identified and additional interventions were put in place, such as additional g-tube flushes, checking/changing of positioning/clothing/linen for residents in bed, etc.
- Facility Administrator and DON initiated a rounding tool to document the 2-hour rounding being completed by nursing management, and ensure the following: Frequent monitoring of residents with mobility concern (bed-bound), Frequent monitoring of residents with compromised ability to verbalize discomfort, Frequent monitoring of resident body temperature, Presence of ice/water/appropriate hydration in the resident room.
- Facility's nursing management, initiated nurses monitoring for signs/symptoms of heat exhaustion and heat stroke every 4 hours; with documentation in the residents' MARs.
- Facility Administrator conducted education to all staff on facility extreme hot weather policy and checking for signs/symptoms of hyperthermia.
- Facility RDO arranged for the Maintenance Director at an affiliated facility to assess the HVAC function, in observation of the PTAC units in the lobby and conference room not working, and anticipation of continuous high temperatures expected during the week. Temperatures on the care units were not noted as a concern at this time.
- Assisting Maintenance Director contacted the facility's contracted HVAC service provider to provide further assessment of the HVAC system and planned to secure parts for repair of the PTAC units in the facility's lobby and conference rooms.
- Assisting Maintenance Director repaired the PTAC unit in the facility's conference room and verified availability and function of 17 window A/C units. The assisting Maintenance Director developed a plan and secured the additional staff needed to install the units.
- Facility's contracted HVAC service provider assessed the HVAC system and performed service to the facility's chillers and compressors; providing the facility with 50% function of the system that provides A/C to the public areas, (hallways and dining rooms). The facility Administrator and management were told that a repair to the rooftop unit will be needed and could be scheduled when outside temperatures subside, however the current function % would be sufficient to provide the amount of A/C necessary to maintain appropriate temperatures throughout the building in the interim.
- Assisting Maintenance Director returned to the facility to install window units on the second floor, where the rooms with the highest temperatures were located. A/C units were installed in the following rooms: 200 (4 bed-room - 2 units installed), 203, 206, 207, 208, 209, 211, 210, 214, 215, 217, 218, 222, 223, 224, Facility lobby.
- Facility's contracted HVAC service provider returned to the facility to do additional assessment and service to the ground level chiller, central A/C units to maximize A/C performance to facility public areas. The provider also initiated assessment and service to the convectors in the resident rooms. The Administrator will ensure that the HVAC service provider provides routine maintenance annually of the HVAC systems, in accordance with the facility PM program.
- Facility's contracted HVAC service provider completed the assessment and service to all the convectors in the residents' rooms. The Administrator will ensure that the convectors are assessed/cleaned/serviced monthly by the Maintenance Director or designee (HVAC service provider). The company's corporate maintenance director or designee (HVAC service provider) will perform quarterly audit of the primary HVAC system to ensure proper maintenance/function in between annual inspections provided by the HVAC service provider. The corporate maintenance director or designee (HVAC service provider) will also complete random audits of the individual room convectors on a quarterly basis to ensure compliance with monthly maintenance.
Failure to Determine Cause of Resident's Injuries
Penalty
Summary
The facility failed to prevent or determine the cause of an injury of unknown origin for a resident, identified as R1, who sustained bruising to the left hip, left hand, and left shin, as well as superficial scratches to the back. R1, a female resident with a history of psychosis, anxiety disorder, acute stress reaction, and adult physical abuse, reported an incident involving rough treatment by an agency staff nurse. Despite R1's intact cognition, as indicated by a BIMS score of 15, her statements were inconsistent with the evidence gathered during the investigation. The facility's report noted discrepancies in R1's account, such as claims of clothing being ripped and multiple staff being present, which were not supported by video evidence. The facility's progress notes and a police report detailed R1's allegations of being forced to shower and physically abused by a nurse, including being pushed, grabbed, and struck with a shower head. However, the facility's investigation, which included reviewing video footage and interviewing staff and residents, did not substantiate these claims. The administrator, V1, noted that the nurse was the only person observed entering R1's room, contradicting R1's account of multiple individuals being involved. Despite the investigation, the facility was unable to determine how R1 sustained her injuries, as no staff reported any incidents of abuse, and R1 was uncooperative in providing further details. The facility's abuse prevention policy mandates documentation and investigation of all incidents, allegations, or suspicions of abuse, neglect, or injuries of unknown origin. However, the facility's failure to ascertain the cause of R1's injuries highlights a gap in their ability to protect residents from harm. The administrator acknowledged the lack of information regarding the injuries and the inability to obtain further details from the hospital due to the resident's daughter's refusal to share information. This incident underscores the importance of thorough investigations and effective communication to ensure resident safety and compliance with regulatory standards.
Failure to Honor Resident's Shower Preference
Penalty
Summary
The facility failed to honor a resident's preference for showering, which is a violation of the resident's rights to a dignified existence and self-determination. The resident, identified as R4, reported during an interview that she had never received a shower since her admission to the facility and was unaware of her designated shower days. The surveyor had to inform R4 of her shower schedule, which was set for Monday and Thursday evenings. R4 expressed a preference for using a shower bed, as she had done at home, but was not informed about the availability of a shower chair in the facility. Despite being cognitively intact with a BIMs score of 15, R4 had only received bed baths during her three-week stay at the facility, which did not meet her personal preference for showering. The facility's administrator, identified as V12, acknowledged the lack of specific documentation regarding R4's bathing care and skin assessment. The facility did not have shower sheets for R4, and the administrator stated that they could not provide them. The facility's policy on resident rights emphasizes the importance of providing care that maintains or enhances each resident's dignity and respect, including grooming residents as they wish to be groomed. However, the facility's failure to offer R4 a shower or inform her of the available options did not align with this policy, resulting in a deficiency in honoring the resident's rights.
Failure to Protect Resident from Physical Abuse and Delayed Reporting
Penalty
Summary
The facility failed to protect a resident (R1) from physical abuse by staff and did not promptly report the incident as required by their abuse protocols. The incident occurred on 3/2/24 when R1 was physically abused by a Registered Nurse (V3) after becoming upset when he couldn't heat up food by himself. The nurse, V3, physically intervened by taking R1's hands from the tray cart and placing them on his walker. This intervention escalated into a physical altercation between V3 and R1, with both hitting each other with closed fists. R1 sustained injuries to his head, neck, back, and right finger, resulting in a fracture to his right third digit. Despite the altercation, the facility failed to promptly report the incident, leading to a delay in initiating an abuse investigation. The deficiency was further compounded by the lack of proper documentation and follow-up by facility staff. The Director of Nursing (V2) did not believe the assault occurred at the facility and thought it happened with the EMTs or in the emergency department. Additionally, the facility's abuse prevention program policy, last revised in 01/2019, outlined clear procedures for reporting and preventing abuse, neglect, and mistreatment of residents. However, there were gaps in staff training and awareness, as evidenced by the lack of abuse screens or care plans for R1 in his medical records. The failure to adhere to established protocols and promptly report incidents of abuse highlights a critical lapse in resident safety and protection within the facility.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,920 citations issued within 25 miles in the last 12 months — including the 27 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Oak Lawn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aliya Of Oak Lawn | 0.5 mi | ★★★★★ | 11 | 2 |
| Aperion Care Oak Lawn | 0.7 mi | ★★★★★ | 17 | 0 |
| Thryve Of Burbank | 1.3 mi | ★★★★★ | 18 | 0 |
| Avantara Chicago Ridge | 1.4 mi | ★★★★★ | 5 | 0 |
| Chicago Ridge Snf | 1.9 mi | ★★★★★ | 8 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.