Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
WARREN BARR OAK LAWN
OAK LAWN, IL · 122 certified beds · Last Life Safety survey January 31, 2025
CMS Certification Number 145363 · first certified December 1977
Ownership
Operated by LEGACY HEALTHCARE · For profit - Limited Liability company
- Ownership changed February 1, 2023 (change of ownership)from MANOR CARE OF OAK LAWN (EAST) IL LLC
Position within IL
24 citations — more than 73% of the 666 certified nursing homes in IL. Compared within IL rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 8 citations; the earlier surveys in the window averaged 8. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (December 2025 to March 2026), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was January 2025. Facilities in IL are typically surveyed 11–13 months after the last one (median 12), measured over 759 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
12 of the 24 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 24 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in IL, and nationally. Surveyors differ markedly between states, so the IL figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 24 |
| Median facility in IL | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| December 22, 2022 | 13 |
| April 5, 2024 | 3 |
| January 31, 2025 | 8 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2025-01-31 |
| K-0351 | Install an approved automatic sprinkler system. | 2 | 2025-01-31 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2025-01-31 |
| E-0022 | Establish policies and procedures for sheltering. | 2 | 2025-01-31 |
| E-0007 | Address patient/client population and determine types of services needed. | 2 | 2025-01-31 |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | 1 | 2022-12-22 |
| E-0026 | Establish roles under a Waiver declared by secretary. | 1 | 2024-04-05 |
| E-0037 | Establish staff and initial training requirements. | 1 | 2022-12-22 |
What the citations cover
- Emergency Preparedness Deficiencies 12
- Smoke Deficiencies 10
- Egress Deficiencies 1
- Gas, Vacuum, and Electrical Systems Deficiencies 1
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 12 |
| Smoke Deficiencies | 10 |
| Egress Deficiencies | 1 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
January 31, 2025 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (February 27, 2025) |
| E-0022 | Establish policies and procedures for sheltering. | Deficient, Provider has date of correction (February 27, 2025) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (March 25, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (February 28, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (March 3, 2025) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (February 27, 2025) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (February 27, 2025) |
| K-0909 | Ensure gas and vacuum piping is labeled. | Deficient, Provider has date of correction (February 27, 2025) |
April 5, 2024 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (April 17, 2024) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (April 17, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (April 17, 2024) |
December 22, 2022 — 13 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (February 10, 2023) |
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (February 10, 2023) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (February 10, 2023) |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (February 10, 2023) |
| E-0022 | Establish policies and procedures for sheltering. | Deficient, Provider has date of correction (February 10, 2023) |
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (February 10, 2023) |
| E-0032 | Provide primary/alternate means for communication. | Deficient, Provider has date of correction (February 10, 2023) |
| E-0035 | Provide family notifications of emergency plan. | Deficient, Provider has date of correction (February 10, 2023) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (February 10, 2023) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (February 10, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (February 10, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (February 10, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (February 10, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.