Oak Lawn Respiratory & Rehab: Daily Care Failures - IL
The woman, identified in inspection records only as R6, had severe cognitive impairment and was fully dependent on staff for toileting. When someone finally came at 12:40 PM, her brief was, in her fiancé's words, "heavily soaked with bowel movement and was smelly." He had been sitting at her bedside the entire time.
Federal inspectors cited Landmark of Oak Lawn Rehabilitation and Nursing Center, at 9525 South Mayfield, following a complaint inspection completed January 30, 2026. What they found across two days of observation was not an isolated lapse. All three residents they reviewed for basic daily care had been left in soiled briefs for extended periods. In each case, the nursing assistants assigned to help them either hadn't gotten to them yet or didn't know they were assigned to them at all.
The facility's own care plan for R6 called for "appropriate cleansing and peri-care after each incontinent episode." The Director of Nursing told inspectors that staff are supposed to check incontinent residents every two hours. The facility's written incontinence policy, though undated, states the same: a minimum two-hour check, plus care as needed.
None of that happened for R6 on the morning of January 27.
The first resident inspectors flagged, identified as R3, was a woman with mild cognitive impairment who was also fully dependent on staff for toileting. At 10:05 AM on January 27, she told an inspector she thought she was wet. Seventeen minutes later, at 10:22 AM, inspectors observed her brief. It was dark and blackish in color, with a strong odor of urine and feces.
The nursing assistant on her floor, identified as V19, had clocked in at 7:00 AM. Three hours had passed. "I was passing trays and didn't get a chance to change her," V19 told inspectors. "I am on my way to change her."
The next morning, January 28, R3 still hadn't been changed by 10:42 AM. A different nursing assistant, V20, explained that she had just been pulled from the second floor to the first floor and hadn't gotten to R3 yet. At 10:50 AM, a full eight minutes after that explanation, two CNAs finally provided care. R3's brief at that point was moderately wet with urine.
Her care plan had called for checks every two hours, with washing and drying after each episode.
The third resident, R11, had no cognitive impairment. She was fully aware of her situation and had been waiting. At 10:35 AM on January 28, she told inspectors she had last been changed by the night shift, hours earlier. She had already activated her call light. When V20 responded, R11's brief was moderately wet and brownish in color.
V20, the same nursing assistant who had been pulled between floors and hadn't reached R3, told inspectors she hadn't received any report when she was reassigned. "No nursing assistant was assigned to R11," she said. She said she would change her now.
That detail, a resident with an intact mind waiting in a soiled brief while staff were shuffled between floors with no handoff and no assigned patients, runs through all three cases. The problem wasn't that individual workers refused to provide care. It was that the system for delivering that care had broken down entirely. Workers were pulled mid-shift with no report. Residents fell through the gaps between floors.
The Director of Nursing, identified as V2, spoke with inspectors on January 27. She confirmed the two-hour check standard. She did not dispute the findings.
R6's fiancé, V18, had watched the entire four-hour stretch himself. His account was specific and timed: arrived at 8:40 AM, nobody checked between then and 12:40 PM, staff changed her at 12:40 PM. He was not a complainant quoted from a phone call. He was in the room.
Inspectors reviewed care plans for all three residents. R3's plan documented neuromuscular bladder dysfunction and called for two-hour checks, washing and drying the perineum, and clothing changes after episodes. R6's plan called for cleansing and peri-care after each incontinent episode. R11's plan, for overactive bladder, called for assistance with toileting needs.
The gap between what those plans required and what inspectors observed was not subtle. It was hours wide.
Prolonged contact with urine and feces is not a minor inconvenience. It breaks down skin, creates conditions for pressure injuries, and causes infections. For residents who cannot reposition themselves or call loudly enough to be heard, the risk compounds with every hour.
R3 knew she was wet at 10:05 AM and had to wait while the person responsible for her had been passing breakfast trays. R11 had an intact mind and a working call light and still waited in a soiled brief until nearly 11:00 AM. R6 could not advocate for herself at all, and the person who loved her sat at her bedside counting the hours.
The facility's incontinence policy, the one inspectors pulled and reviewed, was undated. Nobody had written a date on it.
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.
The woman, identified in inspection records only as R6, had severe cognitive impairment and was fully dependent on staff for toileting.
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.