Cycle 1
Health 2025-01-31 · Fire 2025-01-31
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Oak Lawn, IL
Warren Barr Oak Lawn
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
9401 South Kostner Avenue, Oak Lawn, IL
(708) 423-7882
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
122
Certified beds
Average residents
103
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Legacy Healthcare
Operator or chain grouping
Approved since
1977-12-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
90 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.86
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.00
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.69
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.68
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.52
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.73
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.20
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
2.85
CMS adjusted total nurse staffing hours
Case-mix index
1.77
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,739
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.48
Composite VBP score used to determine payment impact.
Payment multiplier
0.9815
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 23.05% · Performance 25.34% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.30
Baseline 7.54% · Performance 6.55% · Measure score 4.30 · Achievement 4.30 · Improvement 3.39
Total nurse turnover
1.90
Baseline 39.13% · Performance 55.93% · Measure score 1.90 · Achievement 1.90 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.49 hours · Performance 2.85 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.35% |
10.72%
2.6 pts worse
|
Worse than the National Rate · Eligible stays 459 · Observed rate 15.03% · Lower 95% interval 11.08% |
| Discharge to community | 57.68% |
50.57%
7.1 pts better
|
Better than the National Rate · Eligible stays 469 · Observed rate 49.68% · Lower 95% interval 52.56% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 95.85% |
95.27%
0.6 pts better
|
Numerator 300 · Denominator 313 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 313 |
| Discharge self-care score | 59.31% |
53.69%
5.6 pts better
|
Numerator 121 · Denominator 204 |
| Discharge mobility score | 62.25% |
50.94%
11.3 pts better
|
Numerator 127 · Denominator 204 |
| Pressure ulcers or injuries, new or worsened | 1.6% |
2.29%
0.7 pts better
|
Numerator 5 · Denominator 312 · Adjusted rate 1.19% |
| Healthcare-associated infections requiring hospitalization | 6.55% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 286 · Observed rate 6.29% · Lower 95% interval 4.38% |
| Staff COVID-19 vaccination coverage | 0.74% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 135 |
| Staff flu vaccination coverage | 98.38% |
42%
56.4 pts better
|
Numerator 182 · Denominator 185 |
| Discharge function score | 57.35% |
56.45%
0.9 pts better
|
Numerator 117 · Denominator 204 |
| Transfer of health information to provider | 87.25% |
95.95%
8.7 pts worse
|
Numerator 89 · Denominator 102 |
| Transfer of health information to patient | 97.38% |
96.28%
1.1 pts better
|
Numerator 186 · Denominator 191 |
| Resident COVID-19 vaccinations up to date | 7.41% |
25.2%
17.8 pts worse
|
Numerator 12 · Denominator 162 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 75.5% |
89.6%
14.1 pts worse
|
93.4%
17.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 83.3% · Q2 76.9% · Q3 73.7% · Q4 67.5% · 4Q avg 75.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 69.6% |
91.6%
22 pts worse
|
95.5%
25.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 69.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.4% |
3.3%
1.1 pts worse
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.1% · Q3 5.3% · Q4 2.5% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 86.5% |
50.3%
36.2 pts worse
|
11.4%
75.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 89.2% · Q2 85.7% · Q3 79.4% · Q4 91.4% · 4Q avg 86.5% |
| Percentage of long-stay residents who lose too much weight | 13.4% |
6.5%
6.9 pts worse
|
5.4%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 16.2% · Q3 5.6% · Q4 13.5% · 4Q avg 13.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.0% |
18.5%
14.5 pts better
|
19.6%
15.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.7% · Q3 5.6% · Q4 5.4% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.1% |
22.8%
11.7 pts better
|
16.7%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 9.7% · Q3 9.7% · Q4 16.1% · 4Q avg 11.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 3.8% |
17.2%
13.4 pts better
|
16.3%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.6% |
15.0%
5.4 pts better
|
14.9%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 8.8% · Q3 6.2% · Q4 14.3% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
1.1%
0.2 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 2.0% · Q4 1.6% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.9% |
21.3%
3.4 pts better
|
19.8%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 17.1% · Q3 17.0% · Q4 27.8% · 4Q avg 17.9% |
| Percentage of long-stay residents with pressure ulcers | 7.8% |
5.2%
2.6 pts worse
|
5.1%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 7.1% · Q3 5.8% · Q4 8.5% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 37.1% |
68.8%
31.7 pts worse
|
81.7%
44.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 41.9% · Q2 39.8% · Q3 35.6% · Q4 31.2% · 4Q avg 37.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.1% |
14.0%
1.9 pts better
|
12.0%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.1% · Observed 11.8% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
2.3%
0.8 pts better
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.8% · Q3 1.1% · Q4 1.4% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 23.0% |
63.0%
40 pts worse
|
79.7%
56.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 23.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.1% |
26.2%
7.9 pts worse
|
23.9%
10.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.1% · Observed 34.4% · Expected 24.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-05 · Fire 2024-04-05
13 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-12-22 · Fire 2022-12-22
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (9 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-31
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2025-02-27
F · Potential for more than minimal harm
2025-01-31
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-02-27
F · Potential for more than minimal harm
2025-01-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-03
F · Potential for more than minimal harm
2025-01-31
K909 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum piping is labeled.
Corrected 2025-02-27
E · Potential for more than minimal harm
2025-01-31
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-03-25
E · Potential for more than minimal harm
2025-01-31
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-01-31
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-02-27
E · Potential for more than minimal harm
2025-01-31
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-02-27
F · Potential for more than minimal harm
2024-04-05
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-04-17
F · Potential for more than minimal harm
2024-04-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-04-17
F · Potential for more than minimal harm
2024-04-05
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-04-17
F · Potential for more than minimal harm
2022-12-22
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-02-10
F · Potential for more than minimal harm
2022-12-22
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2023-02-10
F · Potential for more than minimal harm
2022-12-22
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2023-02-10
F · Potential for more than minimal harm
2022-12-22
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2023-02-10
F · Potential for more than minimal harm
2022-12-22
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2023-02-10
F · Potential for more than minimal harm
2022-12-22
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2023-02-10
F · Potential for more than minimal harm
2022-12-22
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-02-10
F · Potential for more than minimal harm
2022-12-22
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-02-10
F · Potential for more than minimal harm
2022-12-22
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-02-10
F · Potential for more than minimal harm
2022-12-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-02-10
E · Potential for more than minimal harm
2022-12-22
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-02-10
E · Potential for more than minimal harm
2022-12-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-02-10
E · Potential for more than minimal harm
2022-12-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-02-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-01-06
D · Potential for more than minimal harm
2025-11-18
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-12-01
G · Actual harm
2024-07-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-15
G · Actual harm
2024-07-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-15
D · Potential for more than minimal harm
2024-07-24
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-08-15
E · Potential for more than minimal harm
2024-04-05
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-04-05
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-04-05
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-04-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-04-05
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-04-05
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-04-15
E · Potential for more than minimal harm
2024-03-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-03-20
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-03-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-03-20
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-04-15
D · Potential for more than minimal harm
2023-03-17
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-03-29
D · Potential for more than minimal harm
2023-03-17
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-03-29
G · Actual harm
2022-12-22
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-02-10
G · Actual harm
2022-12-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-02-10
F · Potential for more than minimal harm
2022-12-22
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-03-04
F · Potential for more than minimal harm
2022-12-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-10
E · Potential for more than minimal harm
2022-12-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-02-10
D · Potential for more than minimal harm
2022-12-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-10
Penalties and ownership
What sits behind the stars
Ownership
Chaim Rajchenbach Descendants Tr Ua 04282008
5% Or Greater Direct Ownership Interest · Organization
Doros Generation Trust U/A/D 1/3/12
5% Or Greater Direct Ownership Interest · Organization
Oakway Operations LLC
5% Or Greater Direct Ownership Interest · Organization
Benco, Jennifer
W-2 Managing Employee · Individual
Legacy Healthcare Financial Services LLC
Operational/Managerial Control · Organization
Oakway Operations LLC
Operational/Managerial Control · Organization
Shabat, Menachem
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Mercy Circle
Chicago, IL
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Burbank Rehabilitation Center
Burbank, IL
2-star overall rating with 2-star inspections with $207,936 in total fines with 11 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
#3
Avantara Evergreen Park
Evergreen Park, IL
1-star overall rating with 2-star inspections with $351,352 in total fines with 19 recent health deficiencies
Jump out