Warren Barr Oak Lawn: Pain Medication Delay - IL
The resident, identified only as R1 in the inspection record, had undergone a right hip arthroplasty on September 19, 2025. Five days later, hospital discharge records prescribed oxycodone 5mg tablets, one to two tablets by mouth every three hours as needed for acute post-operative pain. The resident transferred to Warren Barr Oak Lawn and was seen by a nurse practitioner on September 25, who noted pain with movement of the leg and ordered oxycodone for pain management.
Twenty-nine tablets of oxycodone arrived at the facility at 7:00 AM that morning.
A staff member signed out the first dose at 9:00 AM.
The resident did not receive it until 4:04 PM.
That is a seven-hour gap between when a nurse pulled the medication and when it reached a patient recovering from major orthopedic surgery, a patient whose care plan, initiated that same day, listed as a goal that the resident would be able to report pain to a nurse and receive a response.
The medication administration record for September 2025 confirmed the 4:04 PM administration time. The facility's own pain policy, revised as recently as July 29, 2025, states that if a pain medication is available, it should be administered, and that after an as-needed pain medication is given, the resident should be reassessed for effectiveness. The policy does not address what should happen in the hours between signing out a controlled substance and actually delivering it to the patient who needs it.
Inspectors cited the deficiency under F0697, which covers the management of pain. The level of harm was recorded as minimal harm or potential for actual harm, and the number of residents affected was listed as few.
Those classifications sit at the lower end of the federal deficiency scale. They do not mean the gap went unnoticed or that it carried no consequence for the person lying in a bed with a surgically reconstructed hip, waiting.
Post-operative hip pain is not abstract. Hip replacement surgery involves cutting through soft tissue, reaming bone, and seating a prosthetic joint. The standard of care in the days immediately following the procedure centers heavily on pain control, not only for comfort but because unmanaged pain limits a patient's ability to participate in the physical therapy that determines whether the surgery succeeds. A resident who cannot move because of pain does not rehabilitate. A resident who does not rehabilitate faces longer recovery, greater risk of complications, and in some cases, a permanent loss of the mobility the surgery was meant to restore.
None of that context appears in the inspection report. What appears is a timeline: medication arrives at 7:00 AM, gets signed out at 9:00 AM, and reaches the resident at 4:04 PM. The report does not explain what happened in those seven hours. It does not say whether anyone checked on R1 during that window, whether R1 reported pain to a nurse, or whether a nurse responded. The care plan said R1 would report pain and a nurse would review and monitor pain levels. Whether that happened is not recorded in what inspectors found.
Warren Barr Oak Lawn is a skilled nursing facility in the southwest suburbs of Chicago. The inspection was conducted in response to a complaint, not as part of a routine annual survey, which means someone, a resident, a family member, or a staff member, raised a concern that prompted regulators to come and look.
What they found was narrow in scope but clear in its outline. A controlled substance, an opioid prescribed specifically for acute surgical pain, was logged out of the medication supply by a staff member at 9:00 in the morning. Seven hours passed. The resident, five days out from hip replacement surgery and documented to have pain with movement, received it in the afternoon.
The nurse practitioner who visited that day noted the pain. The care plan written that day acknowledged the pain. The prescription written the day before specified the pain medication could be given every three hours as needed.
Whether anyone asked R1 about pain during those seven hours, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Warren Barr Oak Lawn from 2025-11-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 30, 2026 · Our methodology
WARREN BARR OAK LAWN in OAK LAWN, IL was cited for violations during a health inspection on November 18, 2025.
The resident, identified only as R1 in the inspection record, had undergone a right hip arthroplasty on September 19, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.