Aliya of Oak Lawn: LVAD Training Failures Put Residents at Risk - IL
That nurse, identified in inspection records only as V4, told inspectors she had received no training on left ventricular assist devices at Aliya of Oak Lawn. She also told them she had not checked the LVAD system or its batteries at the start of her shift the day before, when she rounded on the resident who depends on the device to stay alive.
Inspectors from the Centers for Medicare and Medicaid Services visited the facility on a complaint inspection that ran from mid-September through late September 2025. What they found, across nine interviews with nurses and aides, was the same answer repeated: nobody had been trained.
A left ventricular assist device is a mechanical pump implanted in patients with severe heart failure. It takes over the work of the heart's left ventricle, which can no longer push enough blood through the body on its own. The devices run on batteries. When those batteries fail and are not replaced in time, the pump stops. The facility was caring for two residents with LVADs.
The first resident, identified as R1, carried diagnoses including congestive systolic heart failure, ventricular tachycardia, COPD, and cognitive communication deficits. His most recent cognitive assessment showed moderate impairment, meaning he could not reliably monitor or manage his own device. The second resident, R2, was admitted with chronic systolic congestive heart failure, atrial fibrillation, and a heart assist device. Both residents were entirely dependent on staff to recognize problems, respond to alarms, and ensure the batteries powering their pumps were charged and ready.
On September 17, an RN identified as V3 told inspectors she had not received LVAD training at the facility. An LPN identified as V9 said she had not received training on emergency response to a patient with an LVAD. V4, the nurse who could not locate the battery indicator button, confirmed the same. Later that afternoon, an LPN identified as V1 said she had not received training on emergency response either.
The following morning, a CNA identified as V2 said she had received no LVAD training at the facility. That same day, at 12:41 in the afternoon, the Director of Nursing told inspectors that she expected nursing staff to follow facility policy when caring for residents with LVADs. She then said she had no documentation that staff had received LVAD training in July 2025. "She is learning during this survey," the inspection record states, "that staff did not receive training for the LVAD."
The facility's own assessment tool, dated August 29, 2025, listed LVAD care explicitly under required nurse training. The document identified left ventricular assist devices as a service the facility offers based on resident needs, and it listed LVAD training as a mandatory in-service competency for nurses. The facility wrote that obligation down. Then, by the account of its own director of nursing, it did not carry it out.
The medical director told inspectors on September 18 that there should be at least one nurse on duty at all times who is trained on the LVAD. The inspection record does not indicate whether that standard was ever met.
Interviews continued for another week. On September 24, two LPNs, identified as V18 and V19, both said they had not received LVAD training at the facility. The following day, an LPN identified as V21 said she could not remember whether she had responded to a code blue involving R1. She said she recalled that training was offered in July but could not remember whether she had attended.
That detail, the code blue, appears without elaboration in the inspection record. The report does not describe what happened during that event or what the outcome was.
On September 26, an LPN identified as V20 told inspectors she had not received training on emergency response to a patient with an LVAD. That was the ninth staff member to say so.
The assistant director of nursing, identified as V17, told inspectors on September 24 that she was the designated preceptor for LVAD training and that all nursing staff should have received it. She said she would want training to include return demonstration, hands-on practice that requires a staff member to show they can actually perform a skill, not just watch a video. "Watching videos," she told inspectors, "is not enough training to learn about the LVAD."
That distinction matters. An LVAD controller displays alarms and error codes. The batteries must be swapped on a schedule. The driveline, a cable that exits the patient's body and connects to the external controller, must be protected from damage. In an emergency, a staff member who has only watched a video and never handled the equipment may not be able to act quickly enough, or correctly enough, to prevent a patient from losing pump function.
V4's demonstration with the battery captures what that gap looks like in practice. She was not a new employee unfamiliar with the unit. She was a registered nurse, assigned to a resident with an implanted heart pump, working a shift during which she did not check whether that resident's device was adequately powered. When asked to show inspectors how she would check, she could not.
The facility's own written assessment, completed less than six weeks before inspectors arrived, acknowledged that caring for residents with conditions not listed in standard protocols requires specific staff skill sets and material resources. It named LVAD care as one of those conditions. It named training as the required response. The Director of Nursing told inspectors she had no documentation it happened.
CMS cited the violation at a level of minimal harm or potential for actual harm, affecting a small number of residents. The citation falls under the requirement that facilities ensure staff are trained to provide care during both routine operations and emergencies.
The inspection was conducted in response to a complaint. The record does not identify who filed it.
R1, the resident with cognitive deficits and a mechanical heart pump, cannot check his own batteries. He cannot read his own alarm codes. He cannot call for help in a way that communicates what is wrong with his device. He is dependent, entirely, on the nurses and aides who round on him each shift to know what they are looking at when they pick up that gray battery and to know, without hesitation, where the button is.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 10, 2026 · Our methodology
ALIYA OF OAK LAWN in OAK LAWN, IL was cited for violations during a health inspection on October 8, 2025.
That nurse, identified in inspection records only as V4, told inspectors she had received no training on left ventricular assist devices at Aliya of Oak Lawn.
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.