Landmark of Oak Lawn Rehabilitation and Nursing Ce

In the surveyor’s words

From the most serious findings on record at Landmark of Oak Lawn Rehabilitation and Nursing Ce, in the surveyor’s own words.

• Immediate jeopardy, widespreadF921Jun 27, 2024

  Based on observations, interviews, and record reviews, the facility failed to provide a safe environment and ensure comfortable room temperatures in resident rooms with temperatures above 80 degrees Fahrenheit and humidity above 60%. The facility failed to identify all residents at high-risk for heat stroke/heat exhaustion. The facility failed to follow their extreme weather conditions policy and implement an effective plan to monitor ambient temperatures in resident rooms. The facility failed to develop and implement an effective plan to monitor residents' physical condition and increasing residents' comfort. […]

• Immediate jeopardy, isolatedF600Mar 18, 2024

  Based on interviews and record reviews, the facility failed to protect a resident (R1) from physical abuse by staff and failed to follow their abuse protocols by staff not promptly reporting an incident of resident abuse. This failure applied to one (R1) of four residents reviewed for abuse and resulted in R1 being emergently transferred to the local emergency room for evaluation of pain to his head, neck and ribs and subsequently being admitted for assault and a fracture to his right third digit; this failure also led to a delay in the initiation of an abuse investigation as a result of staff not immediately reporting the abuse. The Immediate Jeopardy began on 3/2/24 when R1 was physically abused by V3 (Registered Nurse). […]

• Actual harm, isolatedF600Jan 9, 2025

  Based on observation, interview and record review, the facility failed to protect a resident with severe cognitive impairment from physical abuse; and failed to follow the facility abuse policy and abuse care planning for one (R1) of five residents reviewed for abuse. This deficiency resulted in R2 hitting R1 in the face. R1 sustained discoloration to left eye, and bleeding to nose and mouth. R1 was sent to the hospital and was diagnosed with facial hematoma as a result of physical trauma. […]

• Actual harm, isolatedF689Nov 27, 2024

  Based on interview and record review, the facility failed to prevent an accident for a resident assessed to require two staff assistance with incontinence care. This failure affected one (R1) of three residents reviewed for falls and resulted in R1 experiencing a fall while being assisted with incontinence care by only one staff member. R1 required emergent hospital transfer for evaluation and sustained a left forehead hematoma, skin tear to right forearm, and left fifth metacarpal fracture. […]

• Actual harm, isolatedF600Jun 27, 2024

  Based on interview and record review, the facility failed to prevent or determine an injury of unknown origin for one resident. This affected one of three residents (R1) reviewed for injury of unknown origin. This failure resulted in R1 sustaining bruising to the left hip, left hand, and left shin and superficial scratches to R1's back and treated at the local hospital. Findings Include: R1 is a [AGE] year old, female resident in the facility with diagnoses of but not limited to: Psychosis not due to substance or known physiological condition, anxiety disorder, acute stress reaction, and adult physical abuse. R1 has a BIMS of 15 (Cognition Intact). Facility Reported Incident with date of occurrence of 3/28/24, reads in part: R1 alleged rough treatment/abuse by agency staff nurse. […]