Above 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 Warren Barr Oak Lawn during CMS and state inspections, most recent first.
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.
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.
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.
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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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 | ★★★★★ | 3 | 0 |
| Thryve Of Burbank | 1.5 mi | ★★★★★ | 18 | 0 |
| Avantara Evergreen Park | 1.8 mi | ★★★★★ | 4 | 0 |
| Landmark Of Oak Lawn Rehabilitation And Nursing Ce | 1.9 mi | ★★★★★ | 2 | 0 |
| Aliya On 87th | 2 mi | ★★★★★ | 18 | 0 |
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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.