Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Warren Barr Oak Lawn during CMS and state inspections, most recent first.
Call lights were not consistently within reach for three residents, including residents who were cognitively intact and able to use them, and wheelchairs were not available for two residents who were assessed to need them for mobility. Staff observed and confirmed that call lights were placed out of reach, and staff also reported that wheelchairs were shared, borrowed, or difficult to find, leaving residents without a wheelchair when they were supposed to get up.
The facility failed to follow infection control practices in several areas. A resident with a gastrostomy tube was not placed on EBP on admission, and a CNA entered the room without the required PPE. A resident who returned from the hospital later found to be COVID-19 positive was not immediately placed in contact/droplet precautions, staff were not promptly informed, required monitoring was not documented per policy, and exposure testing was incomplete. Staff also improperly transported linen without gloves or a bag, and two residents’ CPAP masks were left on nightstands instead of being stored in bags.
A resident with moderate cognitive impairment, bilateral lower extremity impairment, and total urinary incontinence, who required staff assistance for toilet hygiene, was not checked and changed at least every two hours as required by the facility’s incontinence policy. The resident, alert and oriented, reported not receiving incontinence care since the prior evening and was observed in a fully saturated brief with strong ammonia odor, with urine-soaked clothing, bedding, and mattress showing multiple dried rings. Two restorative aides, newly assigned after the prior CNA left the unit, confirmed the resident was heavily soiled, and the assigned CNA acknowledged she had not provided care before being pulled from the floor, despite stating that residents are to be checked and changed every two hours or as needed.
Verbal and Mental Abuse During Search for Missing Belongings: A cognitively intact resident was upset after an MDS nurse and housekeeping director searched through her belongings for missing items and spoke to her in a loud, dismissive, and accusatory manner. Surveyors heard arguing, observed the nurse yell, and found the resident crying and feeling violated, while another resident said staff were talking to her like a child.
A resident was transferred to the hospital without a documented physician order and without sufficient transfer documentation in the chart. The ADON stated the nurse should notify the MD and family, call report to the receiving nurse, complete e-interact and SBAR, and document the change in condition and vital signs, but the record only showed a telehealth visit for cough with thick sputum and sore throat, an order for cough medication, and no further progress notes or transfer documentation. The hospital record later showed the resident came to the ER with cough, SOB, sore throat, and difficulty swallowing, tested positive for COVID-19, and was admitted for treatment.
A resident was transferred to a local hospital, but the facility did not provide written bed-hold information to the resident or the resident's representative. The ADON stated the transferring nurse is expected to give written notice of the bed-hold duration, yet the resident's record had no documentation that the resident or family received it. The facility's bed-hold policy requires written notice to the resident or family members upon transfer.
Failure to Initiate Care Plans for EBP and Enteral Nutrition: A resident admitted with a gastrostomy tube and receiving bolus enteral feedings did not have a person-centered care plan for EBP or enteral nutrition. The IP nurse was unaware of the tube on admission and stated the resident should have been placed on EBP, while the ADON said nurses are expected to initiate EBP for residents with indwelling medical devices. The resident’s care plan lacked EBP interventions, and the compromised nutritional status care plan did not address enteral nutrition.
The facility failed to follow physician orders for two residents. One resident with lymphedema did not have ordered compression Ace wraps applied, and the wraps were found in a nightstand drawer instead of on the legs. Another resident had two Scopolamine patches on the body at the same time, including one on the upper back, even though the order called for only one patch to be applied every three days. An LPN later stated the old patch should have been removed before the new one was applied.
A resident with a displaced R humerus fracture after a fall did not receive ordered PT eval/treat, OT eval/treat, or PROM with pendulum exercises for more than 30 days. Staff reported the orders were missed, therapy screening was not completed, and PROM was started without an assessment. When the resident was later evaluated, the R shoulder showed significant ROM limitation compared with full ROM before the fall, and the restorative documentation and care plan had not been updated to match the resident’s condition.
A resident with a PICC line had a clear dressing that was rolled up at the edges and dated well beyond the 7-day change interval. The DON confirmed PICC dressings are to be changed every 7 days, but there were no active PICC orders on the physician order sheet, no PICC care documented on the MAR, and the resident said no one had touched the PICC site for a while.
The facility failed to ensure an opened insulin lispro vial was labeled with the date opened and/or expiration date. During a medication cart audit, an LPN confirmed the vial and insulin bag were not dated, and the DON stated nursing is expected to mark opened insulin with an open date and expiration date per the facility’s medication storage and labeling policy. The affected resident had type 2 DM with diabetic autonomic neuropathy.
Failure to Obtain Ordered Stat Labs: A resident with alcoholic polyneuropathy, cirrhosis, and hyponatremia had stat lab orders placed for a change in condition, but the order was not entered as stat and the lab was not called. The lab technician said the order was received as routine, not stat, and the resident’s RP eventually called 911 to send the resident to the hospital after waiting for the lab draw. The DON stated stat labs should be completed within 4 hours, and the physician said he expected the orders to be followed.
Delayed diagnostic testing and failure to notify MD: A resident with a history of PE, acute thrombosis, hemiplegia, and aphasia reported LLE pain and swelling, and a duplex scan was ordered. The DON did not know the required timeframe, the test was not completed within 24 hours per the contract, and the MD was not notified that the study had not been performed on time. The radiology result later showed the left GSV was non-compressible, suggestive of superficial venous thrombosis.
A resident with multiple medical conditions experienced two falls, but the facility did not conduct post-fall investigations or update the care plan with new interventions as required by policy. The DON, acting as fall coordinator, confirmed that these steps were not completed.
Failure to administer ordered PRN oxycodone: A resident admitted after hip surgery requested oxycodone for pain rated 6/10, but an RN told her the narcotic was not available and offered acetaminophen instead without checking the convenience box. The DON stated nurses are expected to access controlled meds when needed, and the pharmacist confirmed oxycodone was delivered the next morning; the MAR and controlled substance record were inconsistent regarding when the first dose was given.
A resident with severe cognitive impairment experienced respiratory distress, but facility staff failed to recognize the acute change in condition, resulting in delayed care. Despite the resident's gasping for air and high respiration rate, staff initially assessed the condition as normal. Emergency services were eventually called, and the resident was hospitalized for respiratory failure and sepsis.
The facility failed to prevent and treat pressure ulcers for two residents at high risk. One resident developed a sacral deep tissue injury after inadequate turning and repositioning, with treatment orders not documented as completed. Another resident, admitted without pressure ulcers, developed a similar injury and was later hospitalized. The facility's policy required prompt skin breakdown identification and treatment, but these were not consistently implemented.
A resident with bowel incontinence and an indwelling urinary catheter experienced delays in receiving incontinence care at the facility. Despite activating the call light and requesting assistance, the resident was informed by the Unit Nurse Manager that the CNA was busy, leading to a prolonged wait for care. The resident, who had requested to be moved closer to the nurse's station for quicker help, expressed concerns about the timeliness of staff responses. The care plan lacked specific interventions for bowel incontinence, and the facility's policy on timely care was not adhered to.
The facility failed to follow its COVID-19 testing policy during two separate outbreaks, potentially affecting all residents. In September 2023, staff and residents were not properly tested or contact traced after positive cases were identified. In February 2024, the facility did not document required resident testing, citing computer issues, despite having 96 residents at the time.
A facility failed to notify the attending physician and the resident's family of an outside consultant's order to discontinue anticoagulant medication for a resident with a history of heart conditions and pulmonary emboli. The nurse documented the new orders but did not inform the attending physician or the family, contrary to the facility's policy.
The facility failed to follow physician orders by not applying an antifungal cream to a resident. The medication was not administered from 9/16/23 to 9/19/23 due to unavailability and lack of clarification from the pharmacy. The resident later requested a change to an antifungal powder, which was implemented on 9/21/23.
The facility failed to notify the attending physician of a resident's urine culture and sensitivity results, leading to a delay in changing the antibiotic treatment for a UTI. The nurse did not review the results promptly, and the physician was not informed until several days later, after the resident had completed the ineffective antibiotic treatment.
Call Lights Not Within Reach and Wheelchairs Not Available for Residents
Penalty
Summary
The facility failed to ensure that call lights were consistently within reach for three residents. R23 was observed lying in bed with the call light cord clipped to the wall cord and not within reach. R150 was observed sitting in a wheelchair next to the bed with the call light cord tucked between the headboard and mattress and dangling above the floor, also not within reach. R64, who was alert and oriented to person, place, and time, was observed in bed with the call light cord wrapped around a hand sanitizer container attached to the wall behind the bed; R64 stated that if assistance was needed, the call light could not be reached, and a CNA confirmed it was out of reach. R64’s care plan directed that call lights be kept within reach when in the bedroom or bathroom, and the MDS documented cognitive intactness with one-sided upper extremity impairment. The facility also failed to ensure that wheelchairs were available for residents who were assessed to require them for mobility. R112, who was cognitively intact and documented as using a manual wheelchair, stated that she was supposed to get up on Tuesday and Thursday for two hours but did not have a wheelchair to sit in, and said staff took her wheelchair out of her room for other residents. Staff confirmed that R112 did not have a facility-issued wheelchair and that the wheelchair used for her was shared with another resident based on differing get-up days. Therapy staff stated that the facility had four wheelchairs in therapy for therapy use only. R143, admitted with hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage, pulmonary embolism, thrombosis of the right peroneal vein, and aphasia following cerebral infarction, had a BIMS score indicating cognitive intactness and therapy documentation showing wheelchair use and wheelchair management orders. During interview, R143 stated she wanted to get up out of bed but did not always have a wheelchair available and had to stay in bed. No wheelchair was observed in the room, and a CNA stated that lack of a wheelchair was a common problem and that staff had to borrow or look for wheelchairs to get residents out of bed. Additional staff stated wheelchairs were hard to come by, were borrowed from other residents, and that the facility had more patients than wheelchairs available.
Infection Control Failures With EBP, COVID-19 Isolation, Linen Handling, and CPAP Storage
Penalty
Summary
The facility failed to follow its infection prevention and control policies in multiple situations involving residents with special precautions. One resident with a gastrostomy tube was admitted on 3/14/26, and staff did not place the resident on enhanced barrier precautions upon admission. Observations on multiple days showed no signage on the resident’s door and no PPE bin outside the room. A CNA was observed entering the room to provide direct care without donning the required PPE. The infection prevention nurse stated the resident should have been placed on EBP because of the gastrostomy tube, and the ADON stated that nurses are expected to initiate EBP upon admission for residents meeting the criteria. The facility also failed to promptly place a resident who returned from the hospital with COVID-19 in appropriate transmission-based precautions and failed to carry out the required monitoring and exposure response. The resident returned from the hospital on 4/13/26, but there was no isolation signage or isolation cart at the room when observed the next day, and the resident was not moved to a private room with contact/droplet precautions until later that afternoon. Staff interviews showed that multiple nurses and CNAs were not informed that the resident was COVID-19 positive until after the resident had already returned to the facility and had contact with staff and other residents. The infection prevention nurse stated that the roommate was tested and negative, but no other residents were tested at that time, and exposed therapy staff and residents in the skilled therapy gym were not initially tested. The resident’s record also showed no vital signs documented per the facility’s COVID policy, and the chart did not contain an order for every-4-hour monitoring of vital signs and oxygen saturation, although the facility’s COVID guidelines required that monitoring. The facility further failed to follow accepted infection control practices for handling linen, hand hygiene-related practices, and storage of CPAP masks. An agency CNA was observed removing linen from a bed without gloves, carrying the linen against her body, and transporting it down the hall before placing it in a blue bag; she stated she had not received infection control training from the facility or her agency. In addition, two residents’ CPAP masks were observed sitting on nightstands without bags or coverings, and nurses stated the masks should have been stored in a bag to prevent cross contamination. The facility’s infection prevention policy stated that staff and contract workers are to be educated about current infection control practices and procedures at least annually.
Failure to Provide Timely Incontinence Care and Two-Hour Rounds
Penalty
Summary
The facility failed to follow its incontinence care policy and to ensure that a resident who required assistance with toileting was assessed and provided incontinence care at least every two hours. The resident’s MDS documented moderate cognitive impairment with a Brief Interview for Mental Status score of 12, bilateral lower extremity impairment, a need for substantial/maximal assistance with rolling, partial/moderate assistance for toilet hygiene, and a status of always urinary incontinent. The facility’s Incontinence and Perineal Care Policy, adopted 12/3/15, required staff to perform rounds at least every two hours to check for incontinence during the shift. On observation, the resident, who was alert and oriented to person, place, and time, reported not having received incontinence care since the previous evening and stated that he could smell himself. He was found wearing a saturated incontinence brief with yellow, ammonia-smelling urine covering the entire brief, and his pants, folded bath blanket, sheet, and mattress were wet, with multiple dried large irregular-shaped rings on the bath blanket exceeding the shape of his buttocks. Two restorative aides, recently assigned to the resident after the prior CNA left the unit, confirmed that he was soiled and saturated with strong-smelling urine. The CNA identified as the resident’s assigned aide stated she had not provided care for the resident before being pulled from the floor around 11:30 a.m., and also stated that residents are supposed to be checked and changed every two hours or as needed for incontinence care.
Verbal and Mental Abuse During Search for Missing Belongings
Penalty
Summary
The facility failed to ensure a resident was protected from verbal and mental abuse by staff. The resident was admitted with diagnoses including lumbosacral disc displacement, hyperlipidemia, hypertension, and insomnia, and the MDS documented a brief interview for mental status score of 15/15, indicating the resident was cognitively intact. During the incident, surveyors heard loud arguing in the resident’s room and observed an MDS nurse and the housekeeping director standing around the resident’s bed while the nurse yelled in a stern, loud, and dismissive tone, "I'm done with this," before leaving the room. The resident was found crying in bed with two open bags of belongings near the foot of the bed and stated she felt violated because staff were searching for missing items and throwing her belongings in a disrespectful way. She reported that the nurse held a pair of socks close to her face and asked if they were the missing items, which made her feel accused of lying and spoken to like a child. Another resident present in the room stated staff were yelling and arguing with the resident like she was a child. The housekeeping director later stated the nurse came in to help finish a concern report about missing laundry and that the resident had given permission to go through a bag, but also acknowledged they should have left the room earlier.
Missing transfer order and documentation for hospital transfer
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for a resident’s transfer from the facility to the hospital, failed to obtain a physician order for the transfer, and failed to document the transfer in the resident’s medical record. During interview, the ADON stated that the nurse is expected to notify the physician and the resident’s family when a resident is transferred to the hospital, follow up with emergency room staff, call report to the receiving nurse, complete an e-interact form and SBAR for every resident, and document the change in condition or reason for transfer along with vital signs in the progress notes. For the resident involved, the record showed a physician order for a chest x-ray related to lymphedema, but no order to transfer the resident to the hospital. The resident’s progress note documented a telehealth visit for cough with thick sputum and sore throat, with report of coughing up a large amount of thick phlegm; cough medication was ordered and the nurse was instructed to monitor for fever, worsening cough, shortness of breath, wheezing, or change in sputum color and notify the physician of any change in condition. There was no further documentation in the resident’s record after the telehealth visit, and the MAR showed no cough medication was administered that day. The hospital record later showed the resident presented to the ER for sore throat, cough, and shortness of breath, developed throat irritation after coughing and inability to swallow solids for two days, tested positive for COVID-19, and was admitted for treatment.
Failure to Provide Written Bed-Hold Notice
Penalty
Summary
The facility failed to provide written bed-hold information to one resident or the resident's representative when the resident was transferred to a local hospital. During an interview on 4/17/26 at 8:55 AM, the ADON stated that the nurse transferring a resident to the hospital is expected to give the resident and/or representative written information about the duration of the bed-hold policy. However, the medical record for R130 contained no documentation that R130 or R130's family received written information about bed hold. The facility's bed-hold policy, revised 6/26/25, states that the facility must inform the resident or family members in writing of the duration of bed hold when the resident is transferred.
Failure to Initiate Care Plans for EBP and Enteral Nutrition
Penalty
Summary
The facility failed to initiate a person-centered care plan for enhanced barrier precautions (EBP) and enteral nutrition for one resident admitted with a gastrostomy tube and receiving enteral nutrition. The resident stated that he received bolus feedings via his gastrostomy tube after meals and at bedtime, and the physician order sheet documented an order for 360 mL bolus feedings after meals and at bedtime daily. The infection prevention nurse stated she was not aware the resident had been admitted with a gastrostomy tube and said the resident should have been placed on EBP upon admission because of the tube. The assistant director of nursing stated nurses are expected to initiate EBP upon admission for residents meeting EBP criteria, including those with indwelling medical devices. The resident’s care plan did not note an EBP care plan, and the compromised nutritional status care plan initiated on 3/16/26 did not include interventions related to enteral nutrition. The facility’s care plan policy stated the baseline care plan should include initial goals based on admission orders, physician orders, and dietary orders, and that after the comprehensive assessment the facility would put in place person-centered care plans outlining care for the resident.
Failure to Follow Orders for Compression Wraps and Scopolamine Patch
Penalty
Summary
The facility failed to follow physician orders for compression wraps for a resident with lymphedema. The resident’s physician order directed staff to wrap both lower extremities with compression wraps and Ace bandages at 6:00 a.m. On 4/14/26, the resident, who was alert and oriented to person, place, and time, stated that the Ace wraps for the legs were not applied that day. The resident was observed without the compression Ace wraps in place, and the wraps were found in the top drawer of the nightstand dresser. The resident stated the wraps were supposed to be applied to decrease swelling in the legs. A nurse later stated he normally applies the wraps in the morning with CNA assistance because the resident’s legs are heavy, but he could not recall exactly what happened that day or why he charted the wraps as applied when they were not observed on the resident. The facility also failed to ensure proper use of a Scopolamine transdermal patch for another resident. The physician order directed one Scopolamine patch to be applied transdermally every three days. On 4/15/26, the resident was observed with two patches attached to the body: one behind the left ear dated 4/15/2026 and another on the left posterior upper back with no date written on it. The ADON stated the resident was supposed to have only one patch at a time and that the old patch should have been removed before the new one was applied. The nurse later stated he removed the old patch from behind the left ear and applied a new one behind the right ear, but he was not aware of the patch on the resident’s upper back and did not check the back.
Failure to Follow Ortho Therapy and ROM Orders
Penalty
Summary
The facility failed to follow orthopedic physician orders for a resident with a displaced fracture of the upper right humerus after a fall from bed. The orthopedic consult dated 3/16/26 ordered physical therapy evaluation and treatment, occupational therapy evaluation and treatment, and initiation of pendulum and passive range of motion exercises for the right shoulder, with staff assistance for PROM. The resident was observed on 4/14/26 wearing a black sling on the right arm and reporting that the shoulder was not like it had been before the fall, with limitation noted to the shoulder. The restorative nurse stated the resident did not receive PT, PROM, or pendulum exercises as ordered and that the orders were missed until 4/13/26, more than 30 days after the orthopedic recommendations. She also stated she began PROM without first completing an assessment or evaluation of the right upper extremity and did not notify the orthopedic physician that the ordered services had not been completed. The rehab director stated the resident was not screened by therapy upon return from the hospital and did not receive the required evaluation or rehab screening on 3/12/26 or 3/16/26. On 4/18/26, the occupational therapist evaluated the resident and found a 75-80 degree limitation in flexion and extension of the right shoulder, while the restorative nurse assessed the right arm/shoulder as having 80% limited ROM. Records showed the resident had full ROM before the fall, and the resident’s restorative documentation reflected active ROM to the upper and lower extremities but not the right arm/shoulder. The care plan had not been updated to reflect the changes in the restorative program, and staff did not identify any refusal of restorative programming, pendulum exercises, PT, or OT services.
PICC Dressing Not Changed Per Policy
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids for a resident when needed was not met when the facility failed to follow its intravenous therapy policy for a resident with a PICC line. R121 was admitted with diagnoses including polyneuropathy, infection and inflammatory reaction due to internal left knee prosthesis, and anemia. On observation, R121 was in his room up to a wheelchair and had a PICC in the right upper arm with a clear dressing that was rolled up around the outer edges; the dressing was dated 3/19/26. R121 stated that no one had touched the PICC site for a while and he was not sure why it was there. The DON stated that PICC line dressings are changed every 7 days by the assigned nurse, that the PICC line should be discontinued once medication is completed, and that the site should be flushed before and after medication use. The DON confirmed the date on the PICC dressing and stated there were no active orders for the PICC line and was unsure why orders were discontinued or why the PICC site was not monitored or removed. The current physician order sheet did not document any orders for the PICC line, discontinued orders from 3/13/26 included dressing changes every 7 days and flushing with normal saline before and after medication administration, and the MAR did not document any care to the PICC site. The facility policy stated that all central line dressing changes for PICC lines are to be done every 7 days and as needed, with weekly measurement of the external catheter length and circumference.
Undated Open Insulin Vial
Penalty
Summary
The facility failed to ensure that an opened insulin vial was properly labeled with the date opened and/or expiration date, in accordance with its medication storage policy. During a medication cart audit, the opened insulin lispro vial for a resident diagnosed with type 2 Diabetes Mellitus with Diabetic Autonomic (Poly) Neuropathy was observed without an open date or expiration date on the vial or the insulin bag. The nurse present confirmed that the vial was not dated. The DON stated that when insulin is opened, nursing is expected to write an open date and expiration date on the insulin so it is not used after 28 or 30 days, and also stated that the facility uses its medication storage and labeling policy because it does not have a separate insulin policy.
Failure to Obtain Ordered Stat Labs
Penalty
Summary
The facility failed to follow physician orders to obtain stat lab testing for a resident admitted with alcoholic polyneuropathy, cirrhosis of the liver, and hyponatremia. On 4/14/26, the physician ordered stat labs due to a change in condition, including a comprehensive metabolic panel and urine osmolality/sodium. The unit manager said she entered the lab orders and informed the nurse, but the lab technician later stated the order was received at 4:22 PM and was not entered as stat, and no calls were placed to the lab to notify them that the testing was stat. The resident’s responsible party later reported being tired of waiting for the stat lab draw and called 911 to take the resident to the hospital. The resident was transferred to the hospital that evening, with the hospital record showing arrival at 10:30 PM. The DON stated stat labs should be completed within 4 hours and staff should contact the physician if they are not done in that time frame and document it in the progress notes. The physician stated he ordered stat labs for the resident due to the change in condition and expected them to be completed within 4 to 8 hours, but could not recall being informed that the labs were not completed within 4 hours.
Delayed Diagnostic Testing and Failure to Notify Physician
Penalty
Summary
The facility failed to ensure contracted diagnostic services were provided within 24 hours for a resident with a history of pulmonary embolism, acute embolism and thrombosis of the right peroneal vein, hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage, and aphasia following cerebral infarction. On 4/13/26 at 4:31 PM, the resident endorsed pain and swelling in the left lower extremity, and the MD was notified and ordered a doppler of the left lower extremity. The physician order was entered at 4:34 PM for a left duplex scan, veins, extremity, unilateral/limited study. During interviews, the DON stated on 4/15/26 that they did not know the time frame for diagnostic services and could not find the policy, and the doppler had still not been performed at that time. The diagnostic services technician stated the order was received on 4/13/26, that services should be performed within 24 hours, and that they had been busy with orders; a technician was sent on 4/15/26 to perform the service. The MD later stated he would expect the testing to be done within 24 hours and was not notified that the left duplex scan had not been performed within that time frame. The radiology report dated 4/15/26 at 6:12 PM showed the left great saphenous vein was non-compressible, suggestive of superficial venous thrombosis, and the resident's progress notes did not document notification to the doctor or attempts made to contact diagnostic services about the doppler order.
Failure to Investigate Falls and Update Care Plan
Penalty
Summary
The facility failed to follow its fall occurrence policy by not conducting a post-fall investigation to determine the reasonable cause of two falls experienced by a male resident with dementia, hemiplegia, hemiparesis, heart failure, and a urinary tract infection. The resident had two documented falls, but the Director of Nursing, who also serves as the fall coordinator, acknowledged that no post-fall investigation was completed for either incident. Additionally, the resident's fall care plan was not reviewed or revised with new interventions following these falls, as required by the facility's policy. The facility's policy specifies that the fall coordinator should review incident reports, conduct investigations to determine the cause of falls, and update the care plan with appropriate interventions, none of which were completed in these instances.
Failure to Administer Ordered PRN Oxycodone
Penalty
Summary
The facility failed to follow physician orders for as needed oxycodone for a resident admitted after a right hip arthroplasty. The resident stated that on admission she requested oxycodone for pain rated 6 out of 10, but was told her medication had not been delivered yet. The resident also stated that the oxycodone was delivered the next day and she received a dose around 9:00 AM. The resident’s hospital record showed an order for oxycodone 5 mg tablets, 1 to 2 tablets by mouth every three hours as needed for acute post-operative pain, and the facility’s pain policy stated that if the medication was available in the convenience box, it was to be administered and the resident reassessed for effectiveness. The nurse assigned to the resident stated that when the resident requested oxycodone during the evening shift, she told the resident the narcotic was not available and offered acetaminophen instead, but did not check the convenience box for the medication. The DON stated that nurses are expected to sign out controlled substances when administered and can obtain an authorization code to access the convenience box if the medication has not yet been delivered. The pharmacist stated that 29 tablets of oxycodone were delivered to the facility at 7:00 AM the next day, and no access codes were given to any nurse for oxycodone before then. The record also showed oxycodone was signed out at 9:00 AM on 9/25/25, but the MAR did not document administration until 4:04 PM that day.
Failure to Recognize Acute Change in Resident's Condition
Penalty
Summary
The facility failed to recognize an acute change in condition for a resident, resulting in a delay in care. The resident, who has severe cognitive impairment and is dependent on staff for all activities of daily living, was observed by a surveyor to be in respiratory distress, gasping for air with a high respiration rate. Despite this, the nursing staff, including a registered nurse and an LPN, initially assessed the resident's condition as normal for their baseline and did not take immediate action. Vital signs taken earlier in the day were inconsistent with the resident's observed condition, and the staff failed to recognize the severity of the situation. The resident's condition did not improve, and emergency paramedics were eventually called when the resident's breathing worsened and blood pressure dropped. The resident was transferred to the hospital and admitted to the neurological intensive care unit for respiratory failure and sepsis. The facility's policy requires immediate notification of a change in condition to the resident's physician and family, but this was not adequately followed. The medical group representing the resident's physician and nurse practitioner declined to be interviewed during the investigation.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to implement adequate turning and repositioning protocols to prevent the development of new pressure injuries and did not complete treatment orders for two residents at high risk of developing pressure ulcers. Resident R4, who was cognitively impaired, incontinent, and dependent on staff for mobility, developed a sacral deep tissue injury after turning and bed mobility were not documented during specific shifts. The treatment ordered for R4's sacral wound was not documented as completed on several occasions, and R4 was eventually discharged from the facility. Resident R5, who had severe cognitive impairment and was totally dependent on staff for all activities of daily living, developed a sacral deep tissue injury despite being admitted without any pressure ulcers. The treatment for R5's wound was not signed as completed on a specific date, and R5 was later observed in respiratory distress and transferred to the hospital. The facility's policy required prompt identification and treatment of skin breakdowns, but the necessary interventions, such as turning and repositioning, were not consistently implemented, leading to the development of pressure injuries in both residents.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care assistance for a resident who was experiencing frequent loose stools due to a bowel infection. The resident, who is incontinent of bowel and has an indwelling urinary catheter, requires physical assistance from staff for activities of daily living. On the day of the observation, the resident activated the call light to request incontinence care, but the Unit Nurse Manager, after initially responding, informed the resident that the CNA was busy and would come as soon as possible. Despite the resident's repeated requests and the surveyor's presence, the resident continued to wait for assistance, highlighting a delay in care. The resident, who lacks cognitive impairment, expressed concerns about the timeliness of staff responses to call lights, noting that they often have to call out into the hallway for help. The resident had previously requested to be moved closer to the nurse's station to receive quicker assistance. The care plan for the resident, initiated earlier in the month, noted bowel incontinence but did not include specific interventions related to this issue. The facility's policy on incontinence and perineal care emphasizes the importance of timely care to prevent infection and skin irritation, yet the resident's experience suggests a gap in adherence to this policy.
Failure to Follow COVID-19 Testing Policy During Outbreaks
Penalty
Summary
The facility failed to follow its COVID-19 testing policy during two separate outbreaks, potentially affecting all residents. During the first outbreak in September 2023, a speech therapist and a nurse tested positive for COVID-19, but the facility did not conduct the required contact tracing or resident testing. The Infection Preventionist nurse confirmed that contact tracing should have been done up to 72 hours prior to symptom development, and those identified should have been tested on days 1, 3, and 5. However, the facility was unable to provide any documentation of such testing or contact tracing for September 2023, despite having 103 residents at the time of the outbreak. Additionally, a resident tested positive on 9/13/23, further indicating a lapse in the facility's infection control measures. In the second outbreak starting in February 2024, the facility again failed to adhere to its COVID-19 testing policy. Residents were tested on 2/5/24 and 2/9/24, and staff were tested on 2/6/24, 2/12/24, and 2/19/24. However, there was no documentation of resident testing on 2/16/24 and 2/23/24, as required by the facility's policy. The Infection Preventionist nurse admitted that there were computer issues preventing the submission of testing data into the tracker and could not explain why the testing results were missing. The facility's policy mandates that during an outbreak, testing should continue every 3-7 days until there are no new positive cases for 14 days. The facility census on 2/25/24 documented 96 residents, all of whom were potentially affected by this lapse in testing and documentation.
Failure to Notify Physician of Consultant's Orders
Penalty
Summary
The facility failed to notify the attending physician of an outside consultant's order and recommendations for a resident. The resident, who has a history of acute diastolic congestive heart failure, arteriosclerotic heart disease, multiple subsegmental pulmonary emboli, and acute embolism and thrombosis of the deep vein of the right lower extremity, was hospitalized for chest tightness and underwent a thrombectomy. Upon returning to the facility, the resident was placed on anticoagulant medication. After a follow-up visit to a cardiologist, the resident returned with an order to discontinue the anticoagulant medication on a specified date and to schedule a follow-up appointment in six months. The nurse documented the new orders but failed to inform the attending physician and the resident's family of these changes. The Director of Nursing stated that the expectation is for staff to notify the attending physician of any new orders or recommendations upon a resident's return from an outside appointment and to document this notification in the resident's chart. The attending physician did not recall being informed about the medication discontinuation and stated that usually, the facility staff informs them of any outside consultant recommendations. The facility's policy on notification for change in condition requires immediate notification of the resident, consultation with the resident's physician, and notification of the resident's legal representative or an interested family member when there is a need to alter treatment significantly.
Failure to Administer Antifungal Cream as Ordered
Penalty
Summary
The facility failed to follow physician orders by not applying an antifungal cream to a resident (R3). R3 was readmitted from the hospital with orders for an antifungal cream to be applied three times daily. However, the medication administration record and nursing notes indicate that the antifungal cream was not administered as ordered from 9/16/23 to 9/19/23 due to the medication being unavailable. The pharmacy tech confirmed that the medicated ointment was never delivered to the facility because clarification was needed, which was never received. The MDS coordinator canceled the existing order and input a new order with a stop date, but the antifungal cream was still not administered during the specified period. The treatment nurse noted that R3 requested the medicated ointment be changed to an antifungal powder, which was a house stock item requiring a doctor's order. This change was implemented on 9/21/23. The Director of Nursing (DON) stated that all residents readmitted from the hospital should have their orders verified by multiple nurses to ensure accuracy and that the pharmacy would email nurse managers for any medication clarifications. Despite these protocols, R3 did not receive the prescribed antifungal cream as ordered, leading to a failure in following physician orders and providing appropriate treatment and care.
Failure to Notify Physician of Ineffective Antibiotic Treatment for UTI
Penalty
Summary
The facility failed to notify the attending physician of a resident's urine culture and sensitivity results, which indicated that the antibiotic prescribed for a urinary tract infection (UTI) was ineffective. The attending physician typically prescribes macrobid for UTIs until culture results are available, expecting the nurse to inform them of the results to adjust the treatment if necessary. In this case, the urine culture and sensitivity results were reported to the facility but were not reviewed by the nurse until the following day. The results indicated that macrobid was ineffective against the resident's pseudomonas aeruginosa UTI. The attending physician was not notified until several days later, after the resident had completed the macrobid treatment, leading to a delay in starting the appropriate antibiotic, ciprofloxacin. Interviews with the attending physician, infection prevention nurse, and registered nurse revealed that the facility's protocol requires nurses to review laboratory results daily and notify the physician of any abnormal findings. The nurse who reviewed the urine culture and sensitivity results did not document notifying the physician, and there was no policy specific to notifying physicians of laboratory results. The facility's policy on notification for change in condition requires immediate notification of the physician when there is a need to alter treatment significantly. The resident's medical record confirmed the delay in notifying the physician and changing the antibiotic treatment.
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What surveyors actually found near you
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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.
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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) |
|---|---|---|---|---|
| Mercy Circle | 1.1 mi | ★★★★★ | 11 | 0 |
| Thryve Of Burbank | 1.5 mi | ★★★★★ | 5 | 0 |
| Avantara Evergreen Park | 1.8 mi | ★★★★★ | 23 | 0 |
| Landmark Of Oak Lawn Rehabilitation And Nursing Ce | 1.9 mi | ★★★★★ | 2 | 0 |
| Aliya On 87th | 2 mi | ★★★★★ | 18 | 0 |
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 October 2026) and official state health department websites.