Warren Barr Oak Lawn
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the
interview and record review, the facility failed to follow its fall occurrence policy by not conducting a post-fall investigation to determine the reasonable cause of the fall and reviewing the fall care plan with new interventions. This applies to one of three residents (Resident R2) reviewed for falls in a sample of 14.The findings include:Resident R2 was a [AGE] year-old male admitted on [DATE REDACTED] with an admitting diagnosis including dementia, hemiplegia, hemiparesis, heart failure, and urinary tract infection (UTI).A review of the fall log and nursing progress notes documented that the two falls occurred to Resident R2 on 10/30/25 and 11/7/25.On 12/24/25 at 12:25 PM, V2 (Director of Nursing/Fall coordinator) stated, I am the one investigating after a resident fall and then revising the fall care plan with new interventions. I don't have the post-fall investigation completed for Resident R2 for
the falls on 10/30 and 11/7. I know I am supposed to investigate and update the fall care plan with new interventions based on the root cause of the fall.A review of Resident R2's fall care plan indicates any revisions with new interventions to prevent further falls following the falls on 10/30/25 and 11/7/25.A review of the facility presented the Fall Occurrence policy reviewed on 6/30/25 document:5. The fall coordinator will review the incident report and may conduct his/her own fall investigation to determine the reasonable cause of the fall8. The fall coordinator will add the interventions to the resident's care plan.
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
Event ID:
WARREN BARR OAK LAWN in OAK LAWN, IL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in OAK LAWN, IL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WARREN BARR OAK LAWN or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.