The October inspection at Lakewood Nursing & Rehab Center found that staff lacked basic education about Left Ventricular Assist Devices, even as the facility accepted two residents who depended on the machines to keep their hearts pumping.
V12, an agency licensed practical nurse, told inspectors she had cared for resident R1 on October 12 but had never received LVAD training or education from the facility. When R1's condition changed, registered nurse V17 was working in the same area of the building. He also had not received any training about the devices.
The facility's own assessment identified itself as capable of accepting and caring for residents with LVADs, noting two active residents in that category as of October 10. But the training records told a different story.
R1 was initially admitted in May and discharged on May 30, then readmitted on August 11 with a diagnosis that included presence of a heart assist device. R4 was admitted July 17, also with a heart assist device diagnosis.
The facility's director of nursing admitted the system had failed. V2 said the only LVAD education completed was on May 29 — eleven days after R1's original admission date of May 18. "R1 should not have been accepted for admission before staff received training," she told inspectors.
The May 29 training session reached just 11 nurses, according to the facility's sign-in sheet. But the nursing roster showed 23 nurses on staff, excluding agency workers. That meant at least 12 nurses had not been trained before the inspection.
Agency staff received no training at all. "The facility does not have a system in place to train agency staff," the director of nursing confirmed.
R1 and R4's physician, V21, said facilities should only accept residents with such devices if staff are trained and competent to care for them. "At minimum, nurses should know what these machines are, what they do, and why residents have them — that's Nursing 101."
Left ventricular assist devices are mechanical pumps implanted in patients with severe heart failure. The devices help pump blood from the heart's main pumping chamber to the rest of the body, often serving as a bridge to heart transplantation or as permanent treatment.
V7, a hospital outpatient nurse practitioner with the VAD team, said nurses caring for residents with LVADs should be trained according to facility protocol. After the May training session, she said, the facility should have reached out to her team or the LVAD manufacturer for additional education.
The facility's own assessment tool, last updated October 10, states its purpose is "to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies." The assessment specifically notes that when facilities accept residents with care needs they haven't previously admitted, it helps determine which areas require attention, "such as training, education, and competencies necessary to provide the level and types of care needed for the resident population."
Administrator V1 confirmed that the facility assessment's purpose is to determine necessary resources for competent care, including training.
The training gap affected the facility's entire census of 113 residents, according to the inspection report. When specialized equipment fails or residents experience medical emergencies, untrained staff may be unable to respond appropriately or recognize warning signs.
The inspection classified the violation as having minimal harm or potential for actual harm, but the consequences of inadequate LVAD knowledge can be severe. These devices require specific monitoring and troubleshooting skills that general nursing training doesn't typically cover.
The facility had identified itself as capable of providing this specialized care in its formal assessment. But the reality on the floors was different — agency nurses with no device training and permanent staff members who had never learned the basics of equipment that keeps residents' hearts functioning.
The director of nursing's admission that R1 "should not have been accepted" before staff training occurred highlighted the disconnect between the facility's stated capabilities and its actual preparation to provide safe care for residents with complex medical devices.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lakewood Nrsg & Rehab Center from 2025-10-24 including all violations, facility responses, and corrective action plans.