Landmark of Oak Lawn Rehabilitation and Nursing Ce
9525 South Mayfield, Oak Lawn, IL 60453 · Cook County · 143 certified beds · avg 86 residents/day · certified since Jul 16, 1997
Part of chain: INFINITY HEALTHCARE CONSULTING (69 facilities, chain avg rating 2.0★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, facility-wide · Jun 27, 2024 · F-0921 · triggered by a complaint
The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Why it matters: An unsafe or unclean environment raises the risk of falls, infections, and daily discomfort for residents.
Severity (L): A life-threatening or extremely dangerous situation existed throughout the facility. The single most serious citation CMS can issue.
Corrected: Jul 18, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Mar 18, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Apr 5, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 9, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 18, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 27, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 9, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 27, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 18, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 29, 2023 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 15, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 22, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 15, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 1, 2022 · F-0656
The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Why it matters: Without a complete, working care plan, important needs can slip through the cracks and no one is accountable for results.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 27, 2022 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 1, 2022 · F-0697
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 27, 2022 (Deficient, Provider has date of correction)
All citations in the current public record (55)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jan 30, 2026 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Jan 30, 2026 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Jul 18, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jun 18, 2025 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Jun 18, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Jun 18, 2025 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. · from a complaint |
| Jun 18, 2025 | D · Potential for harm, one-off | The facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. · from a complaint |
| Jun 18, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Jun 18, 2025 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint |
| Jun 18, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Jun 18, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Jun 18, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Feb 26, 2025 | D · Potential for harm, one-off | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. · from a complaint |
| Jan 31, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Jan 9, 2025 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Dec 19, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Dec 19, 2024 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Nov 27, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Nov 4, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Jun 27, 2024 | ▲ L · Immediate jeopardy, facility-wide | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint |
| Jun 27, 2024 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jun 27, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Mar 18, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Dec 18, 2023 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint |
| Dec 8, 2023 | F · Potential for harm, facility-wide | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Dec 8, 2023 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · from a complaint |
| Nov 25, 2023 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Sep 29, 2023 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Sep 29, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Sep 29, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Sep 22, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 22, 2023 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Sep 22, 2023 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Sep 22, 2023 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Sep 22, 2023 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Sep 22, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 22, 2023 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Sep 22, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Sep 22, 2023 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Sep 22, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Aug 27, 2023 | F · Potential for harm, facility-wide | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint |
| Sep 1, 2022 | ▲ G · Actual harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Sep 1, 2022 | ▲ G · Actual harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Sep 1, 2022 | F · Potential for harm, facility-wide | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Sep 1, 2022 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Sep 1, 2022 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 1, 2022 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Sep 1, 2022 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Sep 1, 2022 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Sep 1, 2022 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Sep 1, 2022 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Sep 1, 2022 | D · Potential for harm, one-off | When a resident had a planned discharge, the facility did not make sure the necessary information was communicated to the resident and to the doctors or facility taking over their care. |
| Sep 1, 2022 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Sep 1, 2022 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Sep 1, 2022 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (8 → 2).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 14 | 2 | G ▲ |
| 2023 | 18 | 2 | G ▲ |
| 2024 | 8 | 4 | L ▲ |
| 2025 | 13 | 1 | G ▲ |
| 2026 | 2 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
5 fines totaling $308,189, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Dec 19, 2024 | Fine | $53,784 |
| Nov 27, 2024 | Fine | $14,260 |
| Jun 27, 2024 | Fine | $39,459 |
| Mar 18, 2024 | Fine | $78,085 |
| Sep 22, 2023 | Fine | $122,601 |
| Sep 22, 2023 | Payment Denial | 73 days from Oct 15, 2023 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Illinois avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 1.89 | 2.99 | 3.95 | bottom 5% in Illinois; bottom 1% in the U.S. |
| Registered Nurse hours | 0.43 | 0.63 | 0.69 | bottom 37% in Illinois; bottom 26% in the U.S. |
| Weekend total nurse staffing | 1.77 | 2.67 | 3.50 | bottom 9% in Illinois; bottom 1% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.55 | 0.56 | 0.48 | top 38% in Illinois; top 27% in the U.S. |
| Total nursing staff turnover (%) | 67.0 | 44.5 | 45.8 | bottom 6% in Illinois; bottom 8% in the U.S. |
| RN turnover (%) | 77.3 | 41.8 | 42.9 | bottom 5% in Illinois; bottom 7% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.74, RN 0.62, weekend 2.57. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 4/5 · short-stay residents: 1/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Gubin Enterprises Limited Partnership | Organization | 5% or Greater Direct Ownership Interest | 50% | 01/01/2016 |
| Wiliams, Lauren | Individual | W-2 Managing Employee | NOT APPLICABLE | 01/17/2022 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Can we tour the whole building today, including resident bathrooms and common areas, not just the lobby?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Aliya of Oak Lawn | 0.5 mi | Oak Lawn, IL | ★☆☆☆☆ | 1/5 | abuse |
| Aperion Care Oak Lawn | 0.7 mi | Oak Lawn, IL | ★☆☆☆☆ | 2/5 | abuse |
| Thryve of Burbank | 1.3 mi | Burbank, IL | ★★☆☆☆ | 2/5 | |
| Avantara Chicago Ridge | 1.4 mi | Chicago Ridge, IL | ★★★★☆ | 3/5 | |
| Chicago Ridge SNF | 1.9 mi | Chicago Ridge, IL | ★☆☆☆☆ | 1/5 | abuse |
| Warren Barr Oak Lawn | 1.9 mi | Oak Lawn, IL | ★★★★☆ | 4/5 | |
| Midway Neurological / Rehab Center | 2.0 mi | Bridgeview, IL | ★★☆☆☆ | 2/5 | abuse |
| Aperion Care Burbank | 2.1 mi | Burbank, IL | ★★★☆☆ | 3/5 | |
| Pavilion of Bridgeview, the | 2.4 mi | Bridgeview, IL | ★★★☆☆ | 3/5 | |
| Hickory VLG Nrsg & RHB | 2.6 mi | Hickory Hills, IL | ★★★☆☆ | 3/5 | |
| Nexus at Palos | 2.8 mi | Palos Hills, IL | ★☆☆☆☆ | 1/5 | abuse |
| Mercy Circle | 2.8 mi | Chicago, IL | ★★★★★ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 145942.