Aliya of Oak Lawn: Immediate Jeopardy Neglect Violations - IL
The resident, identified in inspection records only as R1, was living with a Left Ventricular Assist Device, known as an LVAD. The machine does the work a failing heart cannot. It runs on battery power. If the battery dies and the device is not connected to a wall outlet, the resident can die. Checking the battery, ensuring the device is charging, monitoring for alarms, and documenting the resident's condition are not optional tasks for a nurse assigned to a patient with an LVAD. They are the job.
The nurse assigned to R1 during the 11 p.m. to 7 a.m. shift did none of it.
What happened that night was not discovered until after the shift ended. The neglect was not reported to the Illinois Department of Public Health when it occurred. An investigation was not sent to state authorities until weeks later. The nurse, identified as the alleged perpetrator of neglect, was immediately suspended once the facility began acting. She was later terminated, according to the inspection report, because she failed to provide a clear and accurate account of what happened during her shift.
The facility's administrator, who serves as the abuse coordinator, had not ensured the incident was reported on the timeline required. The Regional Director of Operations had to come in to conduct training with the administrator on the facility's own abuse and neglect policy, including what constitutes neglect and what reporting obligations follow from it.
Federal inspectors visited the facility on multiple dates before the immediate jeopardy was formally documented on October 8, 2025. On three separate occasions before that date, inspectors asked to review the facility's LVAD policy, procedures, and protocols. On all three occasions, no policy was produced. A document titled "Left Ventricular Assist Device," dated January 2025 with a review date of September 2025, was finally presented to inspectors at 2:40 p.m. on the day of the completed inspection. It had not existed, or at least had not been accessible, on any of the prior visits.
The policy, when it was finally handed over, described what nursing staff were supposed to do when a resident with an LVAD was admitted: enter orders based on discharge instructions from the hospital or from the LVAD clinic, direct all PT/INR results and equipment concerns to the assigned LVAD clinic, and check that the battery backup was charged. It also stated that LVAD training for nurses would be completed through the LVAD clinic. None of that training had been completed for the nurse who worked R1's overnight shift.
The gap between what the policy described and what actually happened the night R1 was left unchecked is the center of this case. A nurse who had not been trained on LVAD care was responsible for a resident whose survival depended on that care being delivered correctly, every hour, through the night.
The facility's response, once inspectors were present and the immediate jeopardy finding was on the table, moved quickly. The Director of Nursing and nurse managers began conducting in-services on LVAD care starting on the date the jeopardy was identified. Those sessions ran through multiple days and covered the specific failure at the heart of the finding: that LVADs must be connected to a wall outlet at night to maintain battery levels. Staff were also re-trained on rounding and checking on residents at least every two hours.
The immediate jeopardy designation was removed after the facility completed those corrective steps. The inspection report documents the removal. It does not document what R1's condition was during the overnight shift when no one checked, what the battery level read when the shift ended, or whether the device had alarmed at any point and gone unanswered.
What the report does make clear is that this was not a momentary lapse. The nurse did not check vitals. She did not check the battery. She did not plug the device into the wall. She did not round on R1 at any point during an eight-hour shift. And when asked about it afterward, she could not or would not give an accurate account of what she had done. The facility concluded her explanation was neither clear nor truthful and terminated her employment on that basis.
The administrator's failure to report the incident to state authorities in a timely way compounded the original neglect. An incident that should have triggered an immediate report to the Illinois Department of Public Health sat unreported. The investigation was not transmitted until well after the incident occurred. The Regional Director of Operations, arriving to address the immediate jeopardy, found it necessary to walk the facility's own administrator through the abuse and neglect policy that the administrator is designated to enforce.
Aliya of Oak Lawn is located at 6300 West 95th Street in Oak Lawn, a southwest suburb of Chicago. The October 8, 2025 inspection was a complaint survey, meaning it was triggered by a complaint filed with regulators rather than a routine scheduled visit.
The LVAD policy the facility eventually produced stated that nursing staff would receive LVAD training through the LVAD clinic. It did not specify how the facility would verify that training had been completed before a nurse was assigned to care for a resident with the device. It did not describe what a nurse should do if the device alarmed during an overnight shift, or what escalation steps were available. Those details were absent from the document inspectors received.
R1 spent a full overnight shift alone with a mechanical heart device, no nurse checking in, no vitals recorded, no battery monitored, no outlet connection confirmed. The facility did not report what happened to state authorities until weeks after the fact. The nurse who was supposed to be there was later fired for not telling the truth about it.
The immediate jeopardy has been lifted. R1's name has not been released.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aliya of Oak Lawn from 2025-10-08 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 2026 · Our methodology
ALIYA OF OAK LAWN in OAK LAWN, IL was cited for immediate jeopardy violations during a health inspection on October 8, 2025.
The resident, identified in inspection records only as R1, was living with a Left Ventricular Assist Device, known as an LVAD.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.