Inspection·October 24, 2025

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few plugged into a wall outlet. V7 stated the data collected from R1's LVAD device on [DATE] showed low battery at 1:39 AM and no external power at 2:22 AM. V7 stated the data showed the device as off at 4:21 AM. On [DATE] at 11:33 AM, V12 (Agency LPN) stated she was assigned to R1 on [DATE]. V12 stated she enlisted the help of V17 (Registered Nurse/RN) and she called 911 when R1 became verbally unresponsive. On [DATE] at 3:52 PM, V17 (RN) said he has never received any LVAD training and has been assigned as R1's nurse once previously. V17 said he had never changed the batteries in an LVAD before, but if he had to, he would call google and find out. V17 said on [DATE], V12 (Agency LPN) told him R1 was not looking good so he went with her to check R1, he noticed labored breathing and went to get oxygen.On [DATE] at 10:33 AM, V12 said the only nurse working on the same side of the building with her on [DATE] was V17 (RN). V12 stated this is her first skilled facility and she usually works in Assisted Living or Memory Care. V12 said she had not had any LVAD training. V12 said the nurse she received report from told her that R1 had a heart monitor but did not call it an LVAD or mention any LVAD assessments that V12 that needed to do. V12 stated that on [DATE], she did not assess R1's LVAD and she was just looking at R1's breathing and took his vital signs. V12 stated when V16 (CNA) told her R1 stopped breathing, V17 went to get the backboard, and then the paramedics showed.On [DATE] at 2:39 PM, V11 (Paramedic) said on [DATE] during R1's CPR, he noticed the satchel next to R1 with a line going into his abdomen. V11 stated he asked V12 (Agency LPN) what the satchel was and V12 told him she did not know. V11 said he continued ALS (Advanced Life Support) for R1.On [DATE] at 2:09 PM, V23 (Firefighter/Paramedic) said R1 was already in cardiac arrest when he arrived at the bedside. V23 stated he asked about the satchel and the guys on the ambulance said the staff told them they didn't know what it was. V23 said he then opened it and saw the two batteries. V23 said he removed the batteries one by one, checked their power/charge level, saw that each battery was dead/black. V23 stated he replaced them both with two batteries from R1's battery charging station and a green light immediately came on. V23 said the LVAD was not plugged in to any other power source besides the two dead batteries. V23 said after he replaced R1's LVAD batteries, he pressed a button on the LVAD main screen, the screen illuminated for the first time and showed some numbers, and he heard the paramedics say R1 had a cardiac rhythm on their monitor. V23 said R1 was then transferred to the hospital.On [DATE] at 4:09 PM, V6 (R1's Son-In-Law/Emergency Contact) said R1 was in the facility because he could not be left by himself since having a stroke. V6 said he thought the facility staff were monitoring R1's LVAD because the facility had to be LVAD certified to take care of R1. On [DATE] at 9:41 AM, V7 (LVAD Nurse Practitioner/NP) said the facility should be assessing and monitoring their LVAD patients according to the facility's policy and procedures. On [DATE] at 4:14 PM, V2 (Director of Nursing-DON) said the facility does not have a policy on LVADs, they follow the LVAD manufacturer Clinical Theory and Operation and System Controller: Alarms & Troubleshooting handout. On [DATE] at 4:05 PM, V2 said V12 (Agency LPN) should have followed the LVAD Emergency Protocol from the LVAD binder kept at the nurse's station. V2 said even if an LVAD resident is managing their own LVAD, if the resident becomes incapacitated, the staff should know how to troubleshoot and manage the LVAD. After Contact the Patient's LVAD Team Immediately, the first intervention showed ASSESS IF PUMP IS RUNNING: Auscultate the left chest over the apex of the heart. A continuous mechanical revving sound indicates the pump is running. Assess the System Controller. If the green pump running symbol [drawn symbol] is illuminated, the pump is running.On [DATE] at 12:03 PM, V21 (R1 and R4's Physician) stated a nurse providing care for an LVAD resident should be trained in LVADs. V21 said the bedside nurse should know basic things about their patients, including what devices/machines their patients have and why they have them. V21 said it is a standard expectation that the bedside nurse should be checking (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the battery of the LVAD at a minimum every shift during their nursing assessment. R1's Face sheet shows he was first admitted to the facility on [DATE] with diagnoses of chronic combined systolic and diastolic congestive heart failure, atrial fibrillation, presence of heart assist device, ischemic cardiomyopathy, cerebral infarction due to embolism of bilateral carotid arteries, and need for assistance with personal care. R1's Care Plan (initiated [DATE]) showed R1 is at potential risk for cardiac complications related to diagnosis including hypertension, atrial fibrillation, stroke, congestive heart failure, cardiomyopathy, peripheral vascular disease, heart assist device and sedentary lifestyle causing deconditioning. R1's POS (Physician Order Sheet) as of his discharge to hospital on [DATE] does not show any orders for LVAD assessment, such as auscultating heart sounds or checking LVAD battery function/charge status.On [DATE] at 1:11 PM, V7 (VAD Team NP) stated R1 expired on [DATE].2. R4's Face sheet shows an initial admission date of [DATE] with diagnoses unstable angina, chronic systolic and diastolic congestive heart failure, ventricular tachycardia, end stage heart failure, atrial fibrillation, hypertension, and presence of heart assist device. On [DATE] at 12:05 PM, R4 said he has been missing the power cord for his mobile power unit to connect his LVAD to wall electricity while he sleeps at night. R4 said he is afraid his batteries will die while he is asleep because they only last seven hours. R4 said he has been missing the cord since he was admitted and the staff are aware, and he asked them to contact the LVAD team to send his missing cord. On [DATE] at 2:05 PM, R4 said the staff have come to him and he has taught them about his LVAD, and he ain't getting paid for this sh*t! R4 then demonstrated how to check the battery charge level and noticed that one of his two batteries was low. He then removed that battery and the LVAD started beeping continuously until he replaced it with a charged battery. R4 then said, See? It's not that hard!On [DATE] at 4:05 PM, V2 (DON) said she was not aware that R4 did not have the necessary LVAD cord to connect to wall electricity at night. On [DATE] at 12:03 PM, V21 (R4's Physician) said it is concerning that R4 does not have the required cord for his LVAD to connect to wall electricity while he sleeps. V21 said he thinks the facility staff should be reaching out to the LVAD team to obtain the missing equipment so R4 does not have to rely on batteries. The facility provided an undated handout from LVAD manufacturer) entitled Clinical Theory and Operation. On page 31 of the handout, it showed Equipment Required for discharge: .One mobile power unit with power cord.---------------------The IJ that began on [DATE] was removed on [DATE] at 12:26 PM when the facility took the following actions to remove the immediacy:LVAD Nursing Care Guideline Policy was adopted and reviewed and approved by Medical Director and LVAD team.u 1.All licensed regular staff nurses received mandatory training on [DATE] by LVAD manufacturer, for emergency LVAD procedures, identifying alarms, and battery replacement. u 3.Plan for new hire and/or agency LVAD training will be completed prior to any shift worked.u 1.Obtained orders for R4, who is residing in the facility, with frequency to monitor LVAD battery function. R4's Care Plan was updated to include LVAD management. Verified R4 has a minimum of 2 fully charged LVAD batteries, and 4 batteries are on charging unit. Mobile power unit with power cord obtained for R4.u 2.LVAD resident POS will include the following LVAD orders: check battery function and level every shift, follow procedure for dressing changes, monitor for signs and symptoms of infection daily and PRN, report to LVAD team if any signs or symptoms of infection are noted, Auscultate heart sounds twice a day, if heart sounds are absent notify the LVAD team at (phone number).u 4.Any potential LVAD admission will be reviewed and discussed by the interdisciplinary team prior to admission and refresher education will be provided as needed. u 5.LVAD Manufacturer's Emergency Care for the Heartmate 3 LVAD patient will be placed in binders at nursing stations and at the bedside of LVAD residents.u 6. Audits will be completed 5 times a week for 4 weeks, then monthly until substantial compliance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety is achieved on the following: -Ensuring orders and monitoring are in place for LVAD battery function and monitoring -LVAD company contact information posted -Ensure a minimum of 2 fully charged LVAD battery units are in place at all times -Care Plan includes LVAD management and battery monitoring - Emergency Care of LVAD Patient guide at nurse's station and bedside -Staff able to articulate and/or teach back steps to ensure device is functioning as intended, including but not limited to battery function and emergency care guide -QAPI will be completed upon acceptable Removal Plan Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145761 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakewood Nrsg & Rehab Center 14716 S Eastern Avenue Plainfield, IL 60544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a training plan was in place to educate licensed staff (including agency staff) on specialty care needs.This has the potential to affect all 113 residents in the facility.Based on interview and record review, the facility failed to ensure a training plan was in place to educate licensed staff (including agency staff) on specialty care needs. This has the potential to affect all 113 residents in the facility. Findings include: The Facility Data Sheet dated 10/14/25 showed the facility's total census was 113 residents. The Facility Assessment Tool (last updated 10/10/25) showed the purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. It also showed that when the facility decides to accept residents with care needs it has not previously admitted , the Facility Assessment 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. The section of the Facility Assessment titled Resident Count - Special Treatment and Conditions showed the facility identified itself as capable of accepting and caring for residents with Left Ventricular Assist Devices (LVADs), noting two active residents in that category as of 10/10/25. R1's face sheet showed R1 was initially admitted to the facility on [DATE] and discharged on 5/30/25. R1's face sheet shows his most recent admission date as 8/11/25 with a diagnosis list that includes presence of heart assist device. R4's face sheet shows an admission date of 7/17/25 with a diagnosis list that includes presence of heart assist device. On 10/17/25 at 10:33 AM, V12 (Agency Licensed Practical Nurse/LPN) said she had cared for R1 on 10/12/25. Per V12, she had never received any LVAD training or education from the facility. V12 stated there was another nurse, V17 (Registered Nurse/RN), who was working in the same area of the building when R1 experienced a change in condition. On 10/15/25 at 3:51 PM, V17 (RN) said he had not received any training about LVADs. On 10/15/25 at 4:14 PM, V2 (Director of Nursing/DON) said the only LVAD In-Service/Education completed was on 5/29/25-11 days after R1's original admission date of 5/18/25. Per V2, R1 should not have been accepted for admission before staff received training. On 10/17/25 at 12:03 PM, V21 (R1 and R4's Physician) said that in general, the facility should only accept residents with devices if the staff are trained and competent to care for those devices. V21 stated at minimum, nurses should know what these machines are, what they do, and why residents have them-that's Nursing 101. On 10/17/25 at 9:41 AM, V7 (Hospital Outpatient Nurse Practitioner with VAD Team) said that nurses caring for residents with LVADs should be trained according to facility protocol. Per V7, after the LVAD In-Service/Education done on 5/29/25, the facility should have reached out to her team or to the LVAD manufacturer to obtain additional training. The facility's LVAD Education sign-in sheet dated 5/29/25 lists 11 nurses who attended the training. Review of the facility's nurse roster shows a total of 23 nurses on staff (excluding agency staff), indicating that at least 12 nurses had not been trained prior to this survey. On 10/24/25 at 11:22 AM, V2 (DON) said the Special Treatments and Conditions section of the Facility Assessment refers to the acuity level the facility is able to care for. Per V2, the facility does not have a system in place to train agency staff. On 10/24/25 at 12:15 PM, V1 (Administrator) confirmed that the purpose of the Facility Assessment is, as stated on the first page, to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies, including training. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145761 If continuation sheet Page 5 of 5