Warren Barr Oak Lawn

Name: Warren Barr Oak Lawn
Address: 9401 SOUTH KOSTNER AVENUE, Oak Lawn, IL, 60453, US
Telephone: 7084237882

9401 South Kostner Avenue, Oak Lawn, IL 60453 · Cook County · 122 certified beds · avg 110 residents/day · certified since Dec 8, 1977

Part of chain: LEGACY HEALTHCARE (89 facilities, chain avg rating 2.9★)

4/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

2.67

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★★☆4/5 · CMS overall rating: 4/5

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)

▲ Actual harm, one-off · Jul 24, 2024 · F-0684 · triggered by a complaint

The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.

Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.

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: Aug 15, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Jul 24, 2024 · F-0686 · triggered by a complaint

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.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

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: Aug 15, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Dec 22, 2022 · F-0726

The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.

Why it matters: Undertrained caregivers are more likely to miss warning signs and make care mistakes.

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: Feb 10, 2023 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Dec 22, 2022 · F-0760

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.

Why it matters: A serious medication error can cause real harm, hospitalization, or worse.

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: Feb 10, 2023 (Deficient, Provider has date of correction)

All citations in the current public record (22)

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
Apr 17, 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
Dec 26, 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
Nov 18, 2025	D · Potential for harm, one-off	The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint
Jul 24, 2024	▲ G · Actual 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. · from a complaint
Jul 24, 2024	▲ G · Actual 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 24, 2024	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
Apr 5, 2024	E · Potential for harm, repeated	The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Apr 5, 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.
Apr 5, 2024	D · Potential for harm, one-off	The facility did not keep residents' personal and medical information private and confidential.
Apr 5, 2024	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.
Apr 5, 2024	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.
Apr 5, 2024	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.
Mar 20, 2024	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. · from a complaint
Mar 20, 2024	D · Potential for harm, one-off	The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Mar 20, 2024	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. · from a complaint
Mar 20, 2024	D · Potential for harm, one-off	The facility did not provide or obtain laboratory tests when a doctor ordered them, or did not promptly report the results back to the doctor who ordered them. · from a complaint
Dec 22, 2022	▲ G · Actual harm, one-off	The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Dec 22, 2022	▲ G · Actual 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.
Dec 22, 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.
Dec 22, 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.
Dec 22, 2022	E · Potential for harm, repeated	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.
Dec 22, 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.

Inspection trend by year

Year	Citations	Serious (G–L)	Worst severity that year
2022	6	2	G ▲
2024	13	2	G ▲
2025	2	0	D
2026	1	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)

No fines or payment denials in the published 3-year window.

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)	2.67	2.99	3.95	top 49% in Illinois; bottom 6% in the U.S.
Registered Nurse hours	0.61	0.63	0.69	top 36% in Illinois; top 47% in the U.S.
Weekend total nurse staffing	2.59	2.67	3.50	top 37% in Illinois; bottom 12% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.74	0.56	0.48	top 21% in Illinois; top 14% in the U.S.
Total nursing staff turnover (%)	52.5	44.5	45.8	bottom 28% in Illinois; bottom 31% in the U.S.
RN turnover (%)	36.4	41.8	42.9	top 43% in Illinois; top 40% 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 3.52, RN 0.81, weekend 3.41. Staffing rating: 2/5.

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: 3/5 · long-stay residents: 3/5 · short-stay residents: 4/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Doros Generation Trust U/A/D 1/3/12	Organization	5% or Greater Direct Ownership Interest	26%	02/01/2023
GPN Family Trust U/A/D 4/28/08	Organization	5% or Greater Direct Ownership Interest	60%	02/01/2023
Oakway Operations LLC	Organization	5% or Greater Direct Ownership Interest	15%	02/01/2023
Benco, Jennifer	Individual	W-2 Managing Employee	NOT APPLICABLE	02/01/2023
Legacy Healthcare Financial Services LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	02/01/2023
Oakway Operations LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	02/01/2023
Shabat, Menachem	Individual	Corporate Officer	NOT APPLICABLE	02/01/2023

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
"How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
"What systems do you use to prevent medication errors, and what happens when one occurs?"
"How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"How do you assess and manage residents' pain, especially for those who have trouble communicating?"
"What percentage of your residents and staff are vaccinated against flu and pneumonia, and how do you offer the vaccines?"
"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
Mercy Circle	1.1 mi	Chicago, IL	★★★★★	4/5
Thryve of Burbank	1.5 mi	Burbank, IL	★★☆☆☆	2/5
Avantara Evergreen Park	1.8 mi	Evergreen Park, IL	★☆☆☆☆	1/5
Landmark of Oak Lawn Rehabilitation and Nursing Ce	1.9 mi	Oak Lawn, IL	★☆☆☆☆	2/5
Aliya on 87th	2.0 mi	Chicago, IL	★★☆☆☆	1/5	abuse
Aliya of Oak Lawn	2.4 mi	Oak Lawn, IL	★☆☆☆☆	1/5	abuse
Aperion Care Burbank	2.5 mi	Burbank, IL	★★★☆☆	3/5
Aperion Care Oak Lawn	2.5 mi	Oak Lawn, IL	★☆☆☆☆	2/5	abuse
Bria of Forest Edge	3.1 mi	Chicago, IL	★★☆☆☆	2/5	abuse
Avantara Chicago Ridge	3.1 mi	Chicago Ridge, IL	★★★★☆	3/5
Smith Village	3.6 mi	Chicago, IL	★★★☆☆	2/5	abuse
Midway Neurological / Rehab Center	3.6 mi	Bridgeview, IL	★★☆☆☆	2/5	abuse

Compare this facility with the 3 closest →

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Facility data as of CMS processing date 2026-08-01. CCN 145363.

The Care File

Visit checklist — Warren Barr Oak Lawn

9401 South Kostner Avenue, Oak Lawn, IL 60453 · 7084237882

Health inspection rating 4/5 · CMS overall 4/5· Fines (3y): $0

Most serious findings on record:

▲ Jul 24, 2024 (F-0684, Actual 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.
▲ Jul 24, 2024 (F-0686, Actual 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.
▲ Dec 22, 2022 (F-0726, Actual harm, one-off): The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.

Questions for the administrator:

☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
☐ "How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
☐ "What systems do you use to prevent medication errors, and what happens when one occurs?"
☐ "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
☐ "What percentage of your residents and staff are vaccinated against flu and pneumonia, and how do you offer the vaccines?"
☐ "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?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 145363 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)