Oak Lawn Respiratory: Pressure Ulcer Care Failures - IL
The January 30 inspection at Landmark of Oak Lawn Rehabilitation and Nursing Center documented what inspectors found when they watched two certified nursing assistants provide incontinence care to the resident, identified in the report only as R3, on the morning of January 28. Her stage 4 sacral wound and stage 4 left ischium wound were visible. The dressings covering them were dirty and peeling off. The date marked on them: January 26.
Two days.
A licensed practical nurse arrived at 11:25 that morning to perform wound care. She said it plainly. The old dressing was soiled, dirty, and peeling off, and the date on it meant nobody had provided wound care the day before.
R3 is described in the report as a woman admitted with mild cognitive impairment, paraplegia, pancreatic cancer, and diabetes. A wound assessment by her wound care physician documented five wounds in total: a stage 4 left hip, a stage 4 sacral wound, a stage 4 left ischium, a stage 4 right buttocks, and a stage 3 right heel. Stage 4 is the most severe classification for a pressure ulcer, meaning the wound has broken through skin and tissue to expose muscle, tendon, or bone.
The physician's order was specific. After cleansing the wound site, staff were to apply a particular product, then cover it with a silicone super absorbent dressing, daily and as needed. The treatment administration record confirmed the order was in place.
When the nurse went to follow it on January 28, she couldn't find the product on the treatment cart.
She told inspectors she knew the product was supposed to be used. It simply wasn't there. She cleansed the wounds with saline, patted them dry, and applied what she had available — medi honey and calcium alginate — to the sacral and left ischium wounds. The ordered product was never applied that day either.
The wound care physician spoke with inspectors the following morning. He confirmed he had ordered the product specifically because it would debride dead tissue from the wound bed. "The facility should have used the product as ordered to change the wound dressing," he said.
The facility provided inspectors with an undated wound care policy. It states that dressing changes are to be performed as ordered by the physician, using clean technique, on all chronic or contaminated wounds. The policy did not help R3 on January 27. It did not locate the missing product on January 28.
Inspectors reviewed three residents for wound care during the complaint inspection. The failure applied to one of them.
R3 came to Landmark of Oak Lawn already carrying wounds that had reached the worst possible stage before she arrived. The care ordered for her was designed to keep those wounds from worsening, to pull dead tissue away so that healing, or at least containment, remained possible. For at least one full day, no one changed her dressings. For the day after that, the nurse who finally did show up to help her couldn't find what she needed to do the job correctly.
The inspection was classified as minimal harm or potential for actual harm. The wounds themselves were already stage 4 when she was admitted. What happens to a stage 4 pressure ulcer on a woman with paraplegia and pancreatic cancer when the dressings go unchanged and the ordered treatment goes missing is not a question the inspection report answers.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Landmark of Oak Lawn Rehabilitation and Nursing Ce from 2026-01-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 2026 · Our methodology
Landmark of Oak Lawn Rehabilitation and Nursing Ce in OAK LAWN, IL was cited for violations during a health inspection on January 30, 2026.
Her stage 4 sacral wound and stage 4 left ischium wound were visible.
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.