Aliya Of Oak Lawn

During this survey the surveyor was not able to identify what the specific orders should be in-place for a resident with an LVAD.

145087 10/08/2025

Aliya of Oak Lawn 6300 West 95th Street Oak Lawn, IL 60453

During a follow-up interview on [DATE] at 4:46pm V6 (Director of Nursing) said she is now the LVAD preceptor for LVAD's, she is working with V5 (Administrator) to establish an order set for patients with an LVAD. R2 admission evaluation dated [DATE], completed by the Nurse denotes in-part disease conditions contributing to admission- heart failure, devices- other- LVAD.

Cardiovascular, ventricular assist device- yes is checked.

Review of the baseline plan of care included in the admission evaluation, there are no goals or interventions noted specifically for the LVAD, there are no orders for checking/monitoring the alarms, system, or batteries.

Review of R2's comprehensive plan of care with V12 (MDS coordinator), V12 stated that she edited/ revised the care plan during this survey on [DATE] to include the LVAD, V12 stated she knew the surveyor was reviewing for LVAD's. V12 was asked, what's the specific goals and interventions for the patient with the LVAD, V12 said the floor nurse are supposed develop a plan of care for baseline care needs upon admission within 24 hours, and the MDS team will review the comprehensive plan of care after. V12 did not give a response of what the baseline care needs are for a resident with an LVAD. V12 said she should not edit a resident record after they have discharged from the facility. On [DATE] at 11:44am V17 (ADON-Assistant Director of Nursing) said she was the preceptor for LVAD training.

Staff should monitor the blood pressure, ensure orders are in place, complete daily weights, be attentive by being alert to alarms from the monitor. V17 omitted what orders should be in-place for a patient with an LVAD.Facility policy titled baseline care plan dated 1/2023 last revision date 01/2025 denotes in-part to provide the staff with guidance on completion of comprehensive person-centered care baseline care planning.

The facility will develop and implement A baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care.

The baseline care plan will be developed within 48 hours of residence admission into the facility.

The baseline care plan will include at a minimum of the following necessary information to properly care for a resident elopement risk fall risk supervision needs behavior interventions activities of daily living needs initial goals based on admission orders physician orders dietary orders therapy services social services pass our recommendations if applicable.

Person centered care means that the facility focuses on the resident as the center [TRUNCATED]

145087 10/08/2025

Aliya of Oak Lawn 6300 West 95th Street Oak Lawn, IL 60453

controller will probably be alarming: device check: check VAD parameters, controller alarm

jeopardy to resident health or controller if instructed by VAD team.

Transport urgently to ER (emergency room).Facility Emergency safety Response, denotes in-part VAD hazard alarm, call VAD team immediately (number listed) If patient is unresponsive: is VAD running? (listen for hum and check VAD numbers) YES: Treat underlying cause

get pump running quickly if unable to quickly okay to administer CPR and/or defibrillate. DO NOT disconnect VAD. If patient is responsive: Step 1-Check the connection between the system controller and the LVAD, (driveline), Step 2-Check the connection between the system controller and the batteries or between the system controller and power-based unit.

Step 3-If the device still fails to operate and patient is stable, call VAD coordinator: (phone number listed).

The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. 1.

Regional Nurse Consultant in-serviced the Director of Nursing regarding the facility's Emergency Protocol and Procedure for a resident with an LVAD on [DATE].

The Director of Nursing and Nurse Managers completed education with nurses on the facility's Emergency Protocol and Procedure for a resident with an LVAD.

The Director of Nursing and Nurse Managers also completed the education provided by the manufacturer (via Teams) to the facility nurses. 2.

The Director of Nursing was in-serviced on [DATE] by the Regional Nurse Consultant regarding emergency response for LVAD system and specialized device care.

The Director of Nursing provided education on [DATE] through [DATE] to licensed and unlicensed nursing personnel on emergency response for LVAD system.

The emergency response procedure will be placed in the resident care plan and at the bedside. 3.

The Director of Nursing and/or Nurse Managers will provide education to current nursing department staff with competency exams when facility admits any specialty care resident specifically LVAD.

This process will be included in the new hire onboarding/orientation process.

The facility nurses will also receive training competencies at minimum quarterly and as needed for staff caring for residents with specialty care needs.4.

The facility has revised its staffing protocols on [DATE] to ensure that at least one staff member trained in LVAD management is always on duty, including during all shifts, weekends, and holidays when there is an LVAD in the facility.

The schedule is now maintained to verify proper coverage and trained staff assigned are being routinely audited by DON/designee. 5.

The Director of Nursing and/or designee has educated licensed nursing staff on [DATE] on recognizing and appropriately responding to LVAD-related emergencies including prioritization of device functions assessment during a code situation.

Mock code drills incorporating LVAD scenarios will be conducted monthly, with documentation and debriefing to reinforce staff knowledge and readiness.

Date: [DATE]

145087 10/08/2025

Aliya of Oak Lawn 6300 West 95th Street Oak Lawn, IL 60453

During this interview, V4 was asked to demonstrate how to check the LVAD batteries to determine the capacity, V4 picked up the gray battery, V4 could not identify where the button was located on the battery to determine if the battery was charged. V4 was observed to flip the battery over and over, V4 did not identify the button on the front of the battery to check the battery capacity.

V4 stated she did not check R1's LVAD system or batteries when rounding on R1 upon the start of the shift on 9/16/25.On 09/17/2025 at 4:09p.m V1 (LPN) said she did not received training on emergency response to a patient with an LVAD.On 09/18/2025 at 10:01am V2 (CNA) said she has not received any training on LVAD system at the [NAME] Oak Lawn. On 09/18/2025 at 12:41pm V6 (Director of Nursing) stated that her expectation is that the Nursing staff follow the facility policy when caring for a resident with a LVAD systems. V6 said she does not have any documentation that the staff received LVAD training in July 2025. V6 said she is learning during this survey that staff did not received training for the LVAD. On 09/18/2025 at 2:17pm V15 (Medical Doctor/ Medical Director) V15 stated that there should be at least one Nurse on duty that is trained on the LVAD. On 09/19/2025 at 12:12pm V11 (CNA) said she did not get training at the [NAME] Oak Lawn nursing home for LVAD. On 09/24/2025 at 11:44am V17 (ADON-Assistant Director of Nursing) said she was the preceptor for LVAD training. V17 said all Nursing staff should have training for the LVAD, V17 said she would like the training to consist of return demonstration to allow for hands on training, V17 said watching videos is not enough training to learn about the LVAD. On 09/24/2025 at 2:43pm V19 (LPN) said he did not get training at [NAME] Oak Lawn for LVAD patients. On 09/24/2025 at 12:42pm V18 (LPN) said he, V18 he did not get training at [NAME] Oak Lawn for LVAD patients. On 09/25/2025 V21 (LPN) said she can't remember if she responded to the code blue for R1. V21 said she remember that the training was offered in July, she doesn't recall the participating in the training. On 09/26/2025 at 1:48pm V20 (LPN) said she did not received training on emergency response to a patient with an LVAD at [NAME] oak lawn.The Facility Assessment Tool dated 08/29/2025 denotes in-part our resident profile, diseases/conditions, physical and cognitive disabilities- categories-heart/circulatory system, congestive heart failure.

Decisions regarding caring for residents with conditions not listed above, facility resources including but not limited to staff skill sets and material resources.

Mandatory in-services related to specific diagnoses or equipment, involvement of Medical Director, corporate resources.

Services and care the facility offers based on our residents' needs, resident support needs, other special needs, dialysis, hospice, ostomy care, tracheostomy care, bariatric care, palliative care, end of life care, LVAD.

Provide person-centered/directed care: Psycho/social/spiritual support: Identify hazards and risks for residents.

Training topics, competencies: general staff-Abuse, Neglect and Exploitation.

Nurses- Left Ventricular Assist Device.