Lakewood Nrsg & Rehab: LVAD Safety Failures - IL
Federal inspectors who arrived at the facility at 14716 S. Eastern Avenue on October 24, 2025, found conditions serious enough to declare immediate jeopardy, the most severe finding CMS issues, reserved for situations where a facility's failures have placed a resident in immediate risk of serious harm or death.
The device at the center of the violation is a left ventricular assist device, or LVAD. It is not a temporary measure. For patients who receive one, it is often what stands between them and cardiac failure. The pump runs on batteries. When those batteries die, the consequences can be swift and catastrophic.
At Lakewood, inspectors found the facility had not ensured a minimum of two fully charged battery units were available for the resident at all times. There was no documentation that battery function was being monitored. There were no orders in the resident's chart governing LVAD management. The care plan did not address the device.
The emergency care guide that LVAD manufacturers provide, the step-by-step instructions for what to do when something goes wrong, was not posted at the nurse's station. It was not at the resident's bedside. It was not, based on what inspectors found, anywhere staff could reach it when they needed it.
When inspectors asked staff to walk through what they would do, the staff could not do it. They could not articulate the steps to confirm the device was functioning. They could not teach back the emergency procedures. The contact information for the LVAD company, the manufacturer's clinical team that exists precisely to support facilities managing patients with these devices, had not been posted.
The sum of it was a resident with a mechanical heart who was being cared for by a staff that had no written plan, no emergency reference, no charged backup batteries, and no demonstrated knowledge of what to do if any part of that system failed.
CMS cited the deficiency under F0684, which covers the requirement that a facility provide care and treatment that meets professional standards. The level of harm was marked immediate jeopardy. The number of residents affected was listed as few, which under CMS definitions means between one and two.
The facility's removal plan, the document a nursing home must submit to show inspectors how it will eliminate the immediate jeopardy, was still pending acceptable completion at the time the inspection report was finalized. CMS requires that quality assurance and performance improvement review be completed as part of that process.
The inspection was triggered by a complaint, not a routine survey cycle. Someone, whether a family member, a staff member, or another party, contacted regulators before inspectors walked through the door.
An LVAD patient in a long-term care setting requires a level of preparation that goes beyond standard nursing. These devices have alarms, controller units, and power sources that staff must understand and respond to correctly. A driveline, the cable connecting the internal pump to the external controller, can become dislodged. Batteries can lose charge faster than expected. Controllers can malfunction. Every one of those scenarios has a protocol, and every one of those protocols requires that staff have both the knowledge and the physical materials to act.
At Lakewood, inspectors found none of that in place.
The resident with the LVAD remained in the facility while these conditions existed. The inspection record does not say how long the gaps had been present before the complaint was filed, or how long before someone with the authority to investigate arrived.
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.
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 7, 2026 · Our methodology
LAKEWOOD NRSG & REHAB CENTER in PLAINFIELD, IL was cited for violations during a health inspection on October 24, 2025.
Federal inspectors who arrived at the facility at 14716 S.
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.