Warren Barr Oak Lawn

Penalties

• Jul 24, 2024 — IDPH fine (Nursing Home Care Act) ($25,000)
• Jul 24, 2024 — IDPH fine (Nursing Home Care Act) ($2,200)

Inspection findings

1. Apr 17, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected May 7, 2026 · CMS health inspection

2. Dec 26, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jan 6, 2026 · CMS health inspection

3. Nov 18, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0697 Quality of Life and Care Deficiencies

     Provide safe, appropriate pain management for a resident who requires such services.

     Corrected Dec 1, 2025 · CMS health inspection

4. Jan 31, 2025 Fire Safety · 8 findings
   • Not serious Scope/severity F

     E0007 Emergency Preparedness Deficiencies

     Address patient/client population and determine types of services needed.

     Corrected Feb 27, 2025 · CMS fire safety

   • Not serious Scope/severity F

     E0022 Emergency Preparedness Deficiencies

     Establish policies and procedures for sheltering.

     Corrected Feb 27, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0311 Smoke Deficiencies

     Have an enclosure around a vertical opening shaft.

     Corrected Mar 25, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Feb 28, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Mar 3, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Feb 27, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Feb 27, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0909 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure gas and vacuum piping is labeled.

     Corrected Feb 27, 2025 · CMS fire safety

5. Jul 24, 2024 Health · 5 findings
   • Not serious Scope/severity D Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Aug 15, 2024 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Aug 15, 2024 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Aug 15, 2024 · CMS health inspection

   • Serious Scope/severity A

     Type A Illinois Nursing Home Care Act violation

     Type A: substantial probability of death or serious harm, or actual harm (1-129). Sections of the Illinois Administrative Code cited: 300.610a), 300.1010h), 300.1210b), and 300.1210d)3). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation: 300.1210b).

     Statement of deficiencies (PDF)

   • Not serious Scope/severity B

     Type B Illinois Nursing Home Care Act violation

     Type B: more likely than not to cause more than minimal harm (1-130). Sections of the Illinois Administrative Code cited: 300.610a), 300.1210b), and 300.1210d)5). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation: 300.1210b) and 300.1210d)5).

     Statement of deficiencies (PDF)

6. Apr 5, 2024 Fire Safety · 9 findings
   • Not serious Scope/severity F

     E0026 Emergency Preparedness Deficiencies

     Establish roles under a Waiver declared by secretary.

     Corrected Apr 17, 2024 · CMS fire safety

   • Not serious Scope/severity D

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Apr 15, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Apr 15, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Apr 15, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

     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 Apr 15, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0693 Quality of Life and Care Deficiencies

     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 Apr 15, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0883 Infection Control Deficiencies

     Develop and implement policies and procedures for flu and pneumonia vaccinations.

     Corrected Apr 15, 2024 · CMS health inspection

   • Not serious Scope/severity F

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Apr 17, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Apr 17, 2024 · CMS fire safety

7. Mar 20, 2024 Health · 4 findings
   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Apr 15, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Apr 15, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0773 Administration Deficiencies

     Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

     Corrected Apr 15, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Apr 15, 2024 · CMS health inspection

8. Dec 22, 2022 Fire Safety · 19 findings
   • Not serious Scope/severity F

     E0004 Emergency Preparedness Deficiencies

     Develop and maintain an Emergency Preparedness Program (EP).

     Corrected Feb 10, 2023 · CMS fire safety

   • Not serious Scope/severity F

     E0007 Emergency Preparedness Deficiencies

     Address patient/client population and determine types of services needed.

     Corrected Feb 10, 2023 · CMS fire safety

   • Not serious Scope/severity F

     E0015 Emergency Preparedness Deficiencies

     Address subsistence needs for staff and patients.

     Corrected Feb 10, 2023 · CMS fire safety

   • Not serious Scope/severity F

     E0018 Emergency Preparedness Deficiencies

     Establish procedures for tracking staff and patients during an emergency.

     Corrected Feb 10, 2023 · CMS fire safety

   • Not serious Scope/severity F

     E0022 Emergency Preparedness Deficiencies

     Establish policies and procedures for sheltering.

     Corrected Feb 10, 2023 · CMS fire safety

   • Not serious Scope/severity F

     E0024 Emergency Preparedness Deficiencies

     Establish policies and procedures for volunteers.

     Corrected Feb 10, 2023 · CMS fire safety

   • Not serious Scope/severity F

     E0032 Emergency Preparedness Deficiencies

     Provide primary/alternate means for communication.

     Corrected Feb 10, 2023 · CMS fire safety

   • Not serious Scope/severity F

     E0035 Emergency Preparedness Deficiencies

     Provide family notifications of emergency plan.

     Corrected Feb 10, 2023 · CMS fire safety

   • Not serious Scope/severity F

     E0037 Emergency Preparedness Deficiencies

     Establish staff and initial training requirements.

     Corrected Feb 10, 2023 · CMS fire safety

   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Feb 10, 2023 · CMS health inspection

   • Serious Scope/severity G

     F0726 Nursing and Physician Services Deficiencies

     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 Feb 10, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Feb 10, 2023 · CMS health inspection

   • Serious Scope/severity G

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Feb 10, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Mar 4, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Feb 10, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Feb 10, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Feb 10, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected Feb 10, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Feb 10, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• BENCO, JENNIFER — w-2 managing employee, NOT APPLICABLE, since 02/01/2023
• SHABAT, MENACHEM — corporate officer, NOT APPLICABLE, since 02/01/2023
• DOROS GENERATION TRUST U/A/D 1/3/12 — 5% or greater direct ownership interest, 26%, since 02/01/2023
• GPN FAMILY TRUST U/A/D 4/28/08 — 5% or greater direct ownership interest, 60%, since 02/01/2023
• LEGACY HEALTHCARE FINANCIAL SERVICES LLC — operational/managerial control, NOT APPLICABLE, since 02/01/2023
• OAKWAY OPERATIONS LLC — 5% or greater direct ownership interest, 15%, since 02/01/2023
• OAKWAY OPERATIONS LLC — operational/managerial control, NOT APPLICABLE, since 02/01/2023