Inspection visit
Inspection
9 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 9 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
Based on observation, interview and record review the facility failed to allow a resident access to a
bedroom shower room for 1 of 1 dependent resident (R10) reviewed for showering assistance.
Residents Affected - Few
Findings include:
On 6/12/2025 at 11:15am R10 was observed in bed, R10 said the nursing staff will not assist me with a
shower because, I will not go to another floor, I have a working shower in my bedroom the door to the
shower room is broken and it has not opened in over a month and that's how long I have not showered, I
spoke to the director of nursing and she told me also to use the upstairs shower room.
On 6/12/2025 at 11:20am V2 (Director of Nursing-DON) said R10 refuses to shower on the upstairs unit her
shower room door will not open, and I don't know how long it's been broken or if the maintenance staff is
aware, she's been offered other shower rooms.
On 6/13/2025 at 9:45am V10(Laundry Supervisor) said I am not in maintenance, I do not have access as to
how long the door has not opened, I did replace the doorknob and it opens now, the entrance to the shower
room is open in the joining room my staff cleans it every day.
On 6/13/2025 at 9:50am this writer and V10 observed the entrance to R10 shower room door open and the
joining room door open, shower room clean and functioning.
An admission record dated 6/13/2025 indicates that R10 has a diagnosis of Quadriplegia, paraplegia,
obesity, muscle weakness. A care-plan dated 9/27/2024 that indicates R10 require assistance with all
activity of daily living with an intervention of bathing and dressing require total assistance and 1 staff for
bathing and dressing (Totally Dependent on staff). A skin monitoring comprehensive CNA shower review
dated 4/16/2025 and 5/21/2025 no other shower sheets.
Facility Policy: Resident Rights
As a resident of this facility, you have the right to a dignified existence and to communicate with individuals
and representatives of choice. The facility will protect and promote your rights as designated below.
Exercise of Rights.
. You have the right to freedom to exercise your rights of this facility and as a citizen or resident of the
United States without fear of discrimination, restraint, interference, coercion or
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 16
Event ID:
145942
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145942
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/18/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Landmark of Oak Lawn Rehabilitation and Nursing Ce
9525 South Mayfield
Oak Lawn, IL 60453
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0550
reprisal.
Level of Harm - Minimal harm
or potential for actual harm
(Free Choice). You must be informed of and may participate in planning your care and treatment and any
changes in your care and treatment.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145942
If continuation sheet
Page 2 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145942
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/18/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Landmark of Oak Lawn Rehabilitation and Nursing Ce
9525 South Mayfield
Oak Lawn, IL 60453
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0554
Allow residents to self-administer drugs if determined clinically appropriate.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to assess resident for safe medication
self-administration. This deficiency affects one (R5) of three residents in the sample of three reviewed for
Medication safety.
Residents Affected - Few
Findings include:
On 6/13/25 at 10:29AM, R5 observed in room, inhaler laying on top of bedside table, no name or open date
available. R5 said she is allowed to have it at bedside.
On 6/13/25 at 10:35AM, V3 (Licensed Practical Nurse) said that residents are not supposed to have
medications at bedside, but some can, V3 said she will check for order.
On 6/13/25 at 11:46AM, V9 said that the self-medication administration assessment for R5 was not
completed on 2/13/25, the assessment lock date was on 6/13/25, indicating it was not completed until
6/13/25. V9 said that the assessment should have been locked on 2/13/25.
On 6/17/25 at 11:07AM, V3 said all medication should be kept inside package so it can have the residents
name, medication name and instructions, and date it was opened and stored in package for infection
control purposes.
On 6/17/25 at 11:31AM, V2 (Director of Nursing) said that the medication kept at bedside should be stored
it the packaging sent from pharmacy, it will include resident name, medication instructions and date
medication was opened.
R5 is admitted on [DATE] with diagnosis listed in part but not limited to multiple sclerosis, chronic
obstructive pulmonary disease, epilepsy unspecified, muscle weakness, diabetes mellitus due to underlying
condition with hyperglycemia, other asthma. Physician order summary report active order 5/29/25 Albuterol
sulfate HFA aerosol solution 108(90) base mcg/act 2 puff inhale orally every 4 hours as needed for
shortness of breath. Active order on 2/13/25- May have inhaler at bedside. Self-administration of
Medications assessment dated [DATE] not completed. Care plan initiated on 6/13/25 for R5 expresses the
desire to self-administer her medications and has capability to administer them safely. R5 will use rescue
Albuterol inhaler per orders.
5.3: Self-Administration of Medication by Residents
Policy: Self-administration medications will be encouraged if it is desired by the resident, safe for the
resident and other residents of the facility, ordered by the attending physician, and approved by the
interdisciplinary team.
Procedure:
4. If the resident demonstrates the ability to safely self-administer medications, a further assessment of the
safety of bedside medication storage is conducted.
c. The medications provided to the resident for bedside storage are kept in the containers dispensed by
UnitedRx.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145942
If continuation sheet
Page 3 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145942
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/18/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Landmark of Oak Lawn Rehabilitation and Nursing Ce
9525 South Mayfield
Oak Lawn, IL 60453
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0554
5. A physician order is obtained to self-administer medications if the above storage and skill assessment
has been approved for the resident by the interdisciplinary team. The order is recorded on the MAR.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145942
If continuation sheet
Page 4 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145942
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/18/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Landmark of Oak Lawn Rehabilitation and Nursing Ce
9525 South Mayfield
Oak Lawn, IL 60453
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0557
Level of Harm - Minimal harm
or potential for actual harm
Honor the resident's right to be treated with respect and dignity and to retain and use personal
possessions.
Based on observation, interview and record review the facility failed to provide a resident with the proper
footwear while up in the dining area and the hallway for 2 of 2 resident's R7, and R8 reviewed for dignity.
Residents Affected - Few
Findings include:
On 6/12/2025 at 2:25pm this writer observed R7 exiting the dining area with out socks or shoes on her feet
and R8 sitting at the dining room table without shoes on his feet.
On 6/12/2025 at 2:30pm V12 (Certified Nursing Assistant-CNA) observed with this writer R7 with out socks
or shoes on her feet, V12 said I'm working over form 11-7 shift I'm assisting her with socks and shoes now,
she's been in the dining room all morning.
On 6/12/2025 at 3:00pm V2 (Director of Nursing-DON) said I expect R7 to have on shoes and socks daily
because she walks the hallway.
An admission record dated 6/13/2025 indicates that R7 has a diagnosis of dementia, need for assistance
with personal care. A care plan dated 12/10/2024 that has a self-care deficit, and I require assistance with
activity of daily living to maintain my highest level of functioning an intervention of aid with activity of daily
living as required per my dependence needs, a risk for falls and to ensure resident has proper footwear and
nonskid socks prior to activity of daily living care dated 12/26/2024.
On 6/12/2025 at 2:35pm V11(Certified Nursing Assistant-CNA) observed with writer R8 in the dining room
without shoes on his feet. V12 said when I started my shift this morning I couldn't find his shoes, V11 and
writer went into R8 room and V11 opened the closet door and located R8 shoes in a plastic bag on the
shelf and said I guess his daughter put them up in the closet.
On 6/12/2025 at 3:00pm V2 said I expect all residents to have socks and shoes on their feet. V2 and writer
observed R8 shoes in the closet on the top shelf in a bag.
An admission record indicates that R8 has a diagnosis of Alzheimer disease, dementia, and need
assistance with personal care. A care plan dated 2/10/2025 that indicates R8 has self-care deficit and
require assistance with activity of daily living to maintain highest level of functioning, an intervention to aid
with all activity of daily living as required per my dependence needs, ensure I am wearing appropriate
footwear that promote exercise, physical and good traction when ambulating or mobilizing in my wheelchair
and during transfers.
Facility Policy: Resident Rights
As a resident of this facility, you have the right to a dignified existence and to communicate with individuals
and representatives of choice. The facility will protect and promote your rights as designated below.
Dignity.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145942
If continuation sheet
Page 5 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145942
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/18/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Landmark of Oak Lawn Rehabilitation and Nursing Ce
9525 South Mayfield
Oak Lawn, IL 60453
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0557
The facility will treat you with dignity and respect in full recognition of your individuality.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145942
If continuation sheet
Page 6 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145942
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/18/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Landmark of Oak Lawn Rehabilitation and Nursing Ce
9525 South Mayfield
Oak Lawn, IL 60453
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to update care plan of resident with
Self-Medication Administration. This deficiency affects one (R5) resident in the sample of three reviewed for
Care plan revision.
Findings include:
On 6/13/25 at 11:26AM, V9 (Regional Nurse Consultant) said that there should be a care plan initiated
when the order for self-medication administration was received, no care plan was initiated on 2/13/25. V9
said the care plan was initiated on 6/13/25.
R5 is admitted on [DATE] with diagnosis listed in part but not limited to multiple sclerosis, chronic
obstructive pulmonary disease, epilepsy unspecified, muscle weakness, diabetes mellitus due to underlying
condition with hyperglycemia, other asthma. Physician order summary report active order 5/29/25 Albuterol
sulfate HFA aerosol solution 108(90) base mcg/act 2 puff inhale orally every 4hours as needed for
shortness of breath. Active order on 2/13/25- May have inhaler at bedside. Self-administration of
Medications assessment dated [DATE] not completed. Care plan initiated on 6/13/25 for R5 expresses the
desire to self-administer her medications and has capability to administer them safely. R5 will use rescue
Albuterol inhaler per orders.
5.3: Self-Administration of Medication by Residents
Policy: Self-administration medications will be encouraged if it is desired by the resident, safe for the
resident and other residents of the facility, ordered by the attending physician, and approved by the
interdisciplinary team.
Procedure:
4. If the resident demonstrates the ability to safely self-administer medications, a further assessment of the
safety of bedside medication storage is conducted.
c. The medications provided to the resident for bedside storage are kept in the containers dispensed by
UnitedRx.
5. A physician order is obtained to self-administer medications if the above storage and skill assessment
has been approved for the resident by the interdisciplinary team. The order is recorded on the MAR.
11. Update the residents care plan quarterly or as indicated by the change in medication scheduling, dose
or change in residents's condition with a reassessment of the resident's knowledge and ability to
self-administer medication.
IDT Care Planning Policy and Procedure (Person- Center Plan of Care) revised 6/2020
Each resident will have a comprehensive assessment completed that will assist in the development of an
individualized (Person- Centered) plan of care that will include goals and interventions aimed
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145942
If continuation sheet
Page 7 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145942
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/18/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Landmark of Oak Lawn Rehabilitation and Nursing Ce
9525 South Mayfield
Oak Lawn, IL 60453
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
to improve or maintain the residents highest level of function, prevent decline, decrease risk of
complications of medical conditions, medications and diagnosis, decrease risk of injury or to promote
comfort at end of life.
1. Each resident will have a comprehensive assessment completed by the interdisciplinary team upon
admission, quarterly and with significant changes and an individualized care plan will be developed and
updated as needed with quarterly assessments, re-admissions, and changes in condition.
8. The care plan schedule will be updated weekly and communicated to team members on the weekly
schedule.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145942
If continuation sheet
Page 8 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145942
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/18/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Landmark of Oak Lawn Rehabilitation and Nursing Ce
9525 South Mayfield
Oak Lawn, IL 60453
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review the facility failed to ensure activities of daily living (ADL)
for dependent resident's, which included showers and grooming of hair and fingernails, was provided for 4
of 4 resident's (R7, R8, R9 and R10) reviewed for activity of daily living.
Residents Affected - Some
Findings include:
On 6/12/2025 at 2:20pm R7 was observed walking out the dining area with hair not combed and heavy
soiled feet.
On 6/12/2025 at 2:25pm V12 said showers are twice weekly I'm from the over night shift and I did not
shower anyone, I'm assisting R7 now with her hair and putting on some socks I don't know when her last
shower was completed her feet are dirty because she takes off her socks and walk around barefoot.
On 6/12/2025 at 3:00pm V2(Director of Nursing-DON) observed with this writer R7 hair not combed, and
heavy soiled feet, V2 said I don't think she had a shower today her feet are not cleaned, and her hair is not
combed, I expect all resident's to be groomed and showered twice weekly and as needed.
An admission record dated 6/13/2025 indicates that R7 has a diagnosis of dementia, need for assistance
with personal care. A care plan dated 12/10/2024 that has a self-care deficit, and I require assistance with
activity of daily living to maintain my highest level of functioning an intervention of aid with activity of daily
living as required per my dependence needs, bathing and dressing I usually require extensive assistance
and 1 person support.
On 6/12/2025 at 2:35pm this writer observed with V11, R8 in the dining area with a full beard.
On 6/12/2025 at 2:38pm V11 said I thought R8 daughter shave him she was just here today.
On 6/12/2025 at 3:00pm V2 said I expect all resident's to be shaved and groomed daily and as needed he
should not have a full beard.
An admission record indicates that R8 has a diagnosis of Alzheimer disease, dementia, and need
assistance with personal care. A care plan dated 2/10/2025 that indicates R8 has self-care deficit and
require assistance with activity of daily living to maintain highest level of functioning, an intervention to aid
with all activity of daily living as required per my dependence needs grooming.
On 6/12/2025 at 2:38pm this writer observed R9 in bed with a full beard and long soiled fingernails.
On 6/12/2025 at 2:40pm this writer observed with V11(Certified Nursing Assistant-CNA) R9 beard and long
fingernails.
On 6/12/2025 at 2:42pm V11 said R9 has a hospice aid that comes in and shaves and cut his fingernails, I
thought she cleaned him up, I'll start cleaning him up now.
On 6/12/2025 at 3:00pm V2 said R9 does have a hospice aid but the CNA assigned daily to him should
ensure that what ever the hospice aid did not do that she does.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145942
If continuation sheet
Page 9 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145942
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/18/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Landmark of Oak Lawn Rehabilitation and Nursing Ce
9525 South Mayfield
Oak Lawn, IL 60453
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
An admission record indicates R9 has a diagnosis of orthopedic care after surgical amputation,
gastrostomy placement, chronic kidney disease. A care plan for self-care deficit that require assistance with
Activity of daily living intervention to aid with all activity of daily living as required per my dependence
needs, personal hygiene.
On 6/12/2025 at 2:15pm this writer observed R10 in bed with long curved fingernails, R 10 said I don't want
my fingernails cut off I want them cut down and I would like a shower.
On 6/12/2025 at 3:05pm V2 observed with writer R10 long curved fingernails and R10 complaint of not
having a shower.
On 6/12/2025 at 3:07pm V2 said that R10 will not allow the staff to cut off her fingernails she never said she
wanted them cut down and R10 refuses showers.
An admission record dated 6/13/2025 indicates that R10 has a diagnosis of quadriplegia, obesity. A care
plan dated 9/27/2024 for self-care deficit and require assistance with activity of daily living for bathing
dressing and personal hygiene.
Facility Policy: Activities of Daily Living (Routine Care)
Policy: Residents are given routine daily care and HS care by a C.N.A. or a nurse to promote hygiene,
provide comfort and provide homelike environment. ADL care is provided throughout the day, evening and
night as care planned and/or as needed. ADL care is coordinated between the resident and the care givers
with emphasis on resident preferences as much as possible.
. Assisting the resident in personal care such as bathing, showering, dressing, eating, hair care, oral care,
nail care, appropriate skin care (as indicated and as per care plan) as well as encouraging participation in
physical social and recreational activities.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145942
If continuation sheet
Page 10 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145942
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/18/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Landmark of Oak Lawn Rehabilitation and Nursing Ce
9525 South Mayfield
Oak Lawn, IL 60453
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and
provide appropriate care for a resident with a feeding tube.
Based on observation, interview and record review the facility failed to ensure that a dependent resident
was not lying flat in bed while an enteral gastrointestinal tract tube feeding was infusing for 1 of 3 residents
(R9) reviewed for tube feeding.
Findings include:
On 6/12/2025 at 11:00am R9 was observed by this writer with head of bed elevated at 20-degree angle and
resident laying low in the bed feet touching the foot board.
On 6/12/2025 at 11:05am V11 (Certified Nursing Assistant-CNA) observed with writer, R9 laying low in bed,
V11 said his hospice CNA left him this way, his head of bed should be at a 40-degree angle to prevent him
from choking and he should be pulled up higher in bed, when his hospice CNA is not here for him I should
be monitoring R9 and proceeded to pull R9 up in the bed and raise the head of the bed to a 40-degree
angle.
V2(Director of Nursing-DON) said all residents with feeding tubes head of bed should be at a 30-40-degree
angle and pulled up in bed to prevent aspiration.
An admission record dated 6/13/2025 indicates that R9 has diagnosis of unspecified protein calorie
malnutrition and gastrostomy status and chronic kidney disease and muscle wasting. An order summary
report dated 6/13/2025 indicates R9 head of bed should be always elevated at a 45-degree angle except
during activity of daily living care every shift. A care-plan dated 1/20/2025 that indicates R9 need
assistance with all activity of daily living as required per dependent needs, bed mobility.
Facility Policy: Guidelines for Enteral Feeding: Adult
Purpose: To provide guidance to qualified licensed clinical staff in hanging and maintaining and managing
and administering tube/feeding and enteral nutrition-to residents to include medication administration.
Procedure:
6. The nurses will elevate the head of the bed 30-45 degrees while the tube feeding is infusing and will
maintain this elevation for 30-45 minutes after the feeding is completed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145942
If continuation sheet
Page 11 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145942
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/18/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Landmark of Oak Lawn Rehabilitation and Nursing Ce
9525 South Mayfield
Oak Lawn, IL 60453
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure oxygen tubing is stored, changed and
dated weekly and as needed. This deficiency affects one (R2) of three residents reviewed for Respiratory
Care.
Residents Affected - Few
Findings include:
On 6/12/25 at 2:25PM, R2 observed in room with oxygen tubing on top of bedside drawer uncovered. R2
said that the staff places it there when he does not need it.
On 6/12/25 at 2:30PM, V2 (Director of Nursing) verified with surveyor oxygen tubing on top of bedside
drawer uncovered and unlabeled, said that oxygen tubing should be placed in a plastic bag when not in use
and stored in the drawer, the tubing is changed weekly or as needed.
R2 is admitted on [DATE] with diagnosis in part but not limited to chronic obstructive pulmonary disease
(COPD), essential hypertension, tobacco use, alcohol abuse, anxiety disorder, human immunodeficiency
virus, unspecified abnormalities of breathing. Physician order summary report active order 6/6/25 Oxygen
at 2-3L/min per nasal cannula every shift for COPD/asthma exacerbation.
Oxygen Administration Policy
Policy: It is the policy of this facility to provide oxygen to maintain levels of saturation to residents as needed
and as ordered by the attending physician. Orders are entered into the clinical under Medication
Administration Record.
Procedures:
4. Tubing, humidifier bottles and filters will be changed, cleaned and maintained no less that weekly and
PRN. Each will be labeled with date, time and initialed by staff completing this service to equipment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145942
If continuation sheet
Page 12 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145942
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/18/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Landmark of Oak Lawn Rehabilitation and Nursing Ce
9525 South Mayfield
Oak Lawn, IL 60453
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on observation, interview and record review, the facility failed to account for the Shift change
accountability record for controlled substances. This deficiency affects one of four medication carts (1st
floor medication cart).
Findings include:
On 6/12/25 at 3:15PM, V5(Licensed Practical Nurse) said that controlled substance check is done daily on
each shift with incoming nurse to verify narcotic count, V5 observed on controlled substance sing in sheet
that dates were missing initials, said that the nurse did not sign.
On 6/12/25 at 3:15PM, V6 (Licensed Practical Nurse) said that controlled substance is counted each day
on each shift. V6 verified that there were dates with missing initials and said that if the initials are not there
it does not mean the count was not done, V6 said she was not here on those dates.
On 6/12/25 at 4:05PM, V2 (Director of Nursing) made aware of above findings with V5 and V6 of empty
spaces not initialed in the days for 6/3/25, 6/10/25 and 6/11/25 and when asked to provide a copy of sheet
the copy was given with all dates filled with initials. V2 said her expectations are that the narcotic sign in
sheet is signed by both nurses one for incoming nurse and the other for nurse who is leaving, the narcotic
count is done every day three times a day for each shift, said she was unaware of missing initials.
On 6/12/25 at 4:15PM, V1(Administrator) said that her expectations for narcotic count is to be done every
day /every shift. Is unaware that some days are not signed off on the narcotic daily sign in sheet. V1 made
aware of empty spaces in the days for 6/3/25, 6/10/25 and 6/11/25 and was asked to provide a copy of
sheet the copy was given with all dates filled. V1 said she understood the concern.
3.3: Controlled Substances
Policy:
Medications classified by the FDA as controlled substances have high abuse potential and may be subject
to special handling, and record keeping.
Procedure:
4. While a controlled substance is in use the nursing staff will maintain the following medication records.
b. All schedule II-controlled substances (and other schedules if facility policy so dictates) will be counted
each shift or whenever there is an exchange of keys between off-going and on-coming licensed nurses. The
two nurses will:
2. Both nurses will count the number of packages of controlled substances that are being reconciled during
the shift/shift count and document on Shift Controlled Substance Count Sheet.
4. Both nurses will sign the Shift/Shift Controlled Substance Count Sheet acknowledging that the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145942
If continuation sheet
Page 13 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145942
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/18/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Landmark of Oak Lawn Rehabilitation and Nursing Ce
9525 South Mayfield
Oak Lawn, IL 60453
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
actual count of controlled substances and count sheet matches the quantity documented.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145942
If continuation sheet
Page 14 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145942
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/18/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Landmark of Oak Lawn Rehabilitation and Nursing Ce
9525 South Mayfield
Oak Lawn, IL 60453
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure the medications are stored safely,
securely, and properly following manufacturer/supplier recommendations. This deficiency affects one
resident (R5) in a sample of three residents reviewed for Self-Administration of Medications by Residents.
Findings include:
On 6/13/25 at 10:29AM, R5 observed in room, inhaler laying on top of bedside table, no name or open date
available. R5 said she is allowed to have it at bedside.
On 6/13/25 at 10:35AM, V3 (Licensed Practical Nurse) said that residents are not supposed to have
medications at bedside, but some can, V3 said she will check for order.
On 6/17/25 at 11:07AM, V3 said all medication should be kept inside package so it can have the residents
name, medication name and instructions, and date it was opened and stored in package for infection
control purposes.
On 6/17/25 at 11:31AM, V2 (Director of Nursing) said that the medication kept at bedside should be stored
it the packaging sent from pharmacy, it will include resident name, medication instructions and date
medication was opened.
R5 is admitted on [DATE] with diagnosis listed in part but not limited to multiple sclerosis, chronic
obstructive pulmonary disease, epilepsy unspecified, muscle weakness, diabetes mellitus due to underlying
condition with hyperglycemia, other asthma. Physician order summary report active order 5/29/25 Albuterol
sulfate HFA aerosol solution 108(90) base mcg/act 2 puff inhale orally every 4hours as needed for
shortness of breath. Active order on 2/13/25- May have inhaler at bedside. Self-administration of
Medications assessment dated [DATE] not completed. Care plan initiated on 6/13/25 for R5 expresses the
desire to self-administer her medications and has capability to administer them safely. R5 will use rescue
Albuterol inhaler per orders.
5.3: Self-Administration of Medication by Residents Policy
Policy: Self-administration medications will be encouraged if it is desired by the resident, safe for the
resident and other residents of the facility, ordered by the attending physician, and approved by the
interdisciplinary team.
Procedure:
4. If the resident demonstrates the ability to safely self-administer medications, a further assessment of the
safety of bedside medication storage is conducted.
c. The medications provided to the resident for bedside storage are kept in the containers dispensed by
UnitedRx.
5. A physician order is obtained to self-administer medications if the above storage and skill
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145942
If continuation sheet
Page 15 of 16
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145942
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/18/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Landmark of Oak Lawn Rehabilitation and Nursing Ce
9525 South Mayfield
Oak Lawn, IL 60453
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
assessment has been approved for the resident by the interdisciplinary team. The order is recorded on the
MAR.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145942
If continuation sheet
Page 16 of 16
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Back to topCitations
9 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F554 - The right to self-administer medications if the interdisciplinary team, as
Allow residents to self-administer drugs if determined clinically appropriate.
F557 - Respect and Dignity
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
FAQ · About this visit
Common questions about this visit
What happened during the June 18, 2025 survey of Landmark of Oak Lawn Rehabilitation and Nursing Ce?
This was a inspection survey of Landmark of Oak Lawn Rehabilitation and Nursing Ce on June 18, 2025. The surveyor cited 9 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Landmark of Oak Lawn Rehabilitation and Nursing Ce on June 18, 2025?
Yes, 9 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.