Inspection·January 30, 2026

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow its Guidelines for Incontinence Care by not providing timely incontinence care to dependent residents. This applies to 3 of 3 residents (R3, R6, and R11) reviewed for activities of daily living in a sample of 11.The findings include:1.R3 is a [AGE] year-old female admitted with mild cognitive impairment as per MDS dated [DATE]. The MDS also documents that R3 is dependent on toileting hygiene.On 1/27/26 at 10:05 AM, R3 was observed in her bed and stated, They changed me last night, and I think I am wet.On 1/27/26 at 10:22 AM, R3 was observed with dark blackish colored incontinent brief with a strong odor of urine and feces.On 1/27/26 at 10:22 AM, V19 (Certified Nursing Assistant / CNA) stated, I got here at 7:00 AM. I was passing trays and didn't get a chance to change her. I am on my way to change her.On January 28, 2006, at 10:42 AM, R3 stated that she had not changed yet. On 1/28/26 at 10:43 AM, V20 (CNA) stated, I was just pulled from the second floor to the first floor now, and I didn't change R3 yet.On 1/28/25 at 10:50 AM, observed V20 and V21 (CNA) providing incontinent care to R3. R3 was observed with a moderate wet brief with urine.A review of the restorative care plan document that R3 was care planned for neuromuscular bladder dysfunction/incontinence with intervention including check the resident (every 2 hours) and as required for incontinence. Wash, rinse, and dry the perineum. Change clothing PRN after incontinence episodes.2.R6 is a [AGE] year-old female admitted on [DATE], having severe cognitive impairment as per the MDS dated [DATE]. The MDS also documents that R6 is dependent on toileting hygiene.On 1/27/26 at 1:00 PM, R6 was observed in her bed with her fiance (V18) at her bedside. V18 stated, I was here at 8:40 AM, and nobody checked on R6 between 8:40 AM and 12:40 PM. R6's incontinent brief was heavily soaked with bowel movement and was smelly, and they changed her at 12:40 PM.A review of the care plan document that R6 was care planned for incontinence with interventions including administering appropriate cleansing & peri-care after each incontinent episode.3.R11 is a [AGE] year-old female admitted on [DATE], having cognition intact as per the MDS dated [DATE]. The MDS also documents that R11 is dependent on toileting hygiene.On 1/28/26 at 10:35 AM, R11 stated, I am waiting to be changed. I was changed in the early morning by the night staff. R11 initiated call light, and V20 checked on R11, and R11 was observed with a moderately wet, brownish colored incontinent brief.On 1/28/26 at 10:40 AM, V20 stated, They just moved me from the second floor, and I didn't get a chance to change R11. I didn't get any report as no nursing assistant was assigned to R11. I am going to change R11 now.A review of the care plan document that R11 was care planned for overactive bladder with interventions including assist with toileting needs.On 1/27/26 at 10:35 AM, V2 (Director of Nursing / DON) stated that their staff is supposed to change incontinent residents every two hours and as needed.A review of the facility provided an undated Guidelines for Incontinence Care document: It's the policy of the facility to ensure that residents receive as much assistance as needed for cleaning the perineum and buttocks after an incontinent episode or with routine daily care. Frequency Residents Affected - Few (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 3 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 01/30/2026 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)