Landmark Of Oak Lawn Rehabilitation And Nursing Ce
Landmark of Oak Lawn Rehabilitation and Nursing Ce in OAK LAWN, IL — inspection on January 30, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Care by not providing timely incontinence care to dependent residents.
This applies to 3 of 3 residents
[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 depends on the bladder's daily result and/or routine minimal every two-hour check, as well as care planning.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
145942 01/30/2026
Landmark of Oak Lawn Rehabilitation and Nursing Ce 9525 South Mayfield Oak Lawn, IL 60453
During incontinence care, R3 was observed with a stage 4 sacral and stage 4 left ischium wound with soiled and dirty dressings peeling off and dated 1/26/26.On 1/28/26 at 11:25 AM, observed V22 (Licensed Practical Nurse / LPN) providing wound care to R3's multiple sacral wounds.
During wound care, V22 stated that the old dressing is soiled, dirty, and peeling off with date 1/26/26 indicates that nobody provides wound care yesterday.On 1/28/26 at 11:30 AM, observed V22 cleanse the wound with saline, pat dry, medi honey, and calcium alginate applied to stage 4 sacral and stage 4 left ischium wounds.A review of the Physician Order Sheet (POS) and Treatment Administration Record (TAR) document sacral and left ischium wound care document to apply (product) after cleansing site and then covering with Silicone super absorbent dressing daily and as needed.On 1/28/26 at 11:30 AM, V22 stated that she is aware of the (product), and she couldn't find it in the treatment cart to apply to R3's sacral and left ischium dressing change.On 1/29/26 at 9:20 AM, V23 (Wound Care Physician) stated, R3 was admitted with those chronic wounds. I ordered (the product), which will debride the dead tissue from the wound bed.
The facility should have used the (the product as ordered) to change the wound dressing.The facility presented an undated Wound Cleansing and Dressing Policy document: It is the policy of the facility to perform wound dressing changes as ordered by the physician using a clean technique on all chronic or contaminated wounds.