F 0573
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Let each resident or the resident's legal representative access or purchase copies of all the resident's
records.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to follow their policy and ensure that medical records were
released in a timely manner when requested by legal representative for one (R4) resident. This failure
affected one resident (R4) in a sample of 5 residents reviewed for policy and procedures.
Findings include:
R4 is an [AGE] year-old resident initially admitted to the facility on [DATE] with diagnoses including but not
limited to: Dementia, Alzheimer's disease, and bipolar disorder. Brief Interview for Mental Status (BIMS)
dated 08/15/2024 documents score of 6 which suggests severe cognitive impairment.
Complaint dated 08/15/2024 provides document signed by legal guardian of R4 on 04/30/2024 which gives
authorization to a law office to request medical records on his behalf for R4.
Complaint dated 08/15/2024 also provides fax transmission result showing success on 04/30/2024 for fax
requesting medical records for R4.
On 08/19/2024 V4 (Quality Assurance/Medical Records) assistant produced documentation dated
05/17/2024 from said law office requesting for second time the medical records for R4. Request included
the HIPAA right of Access to my Designated Record Set form authorizing the law office to request records
signed by legal guardian for R4. V4 also provided email dated 05/23/2024 from their legal team stating that
legal will fill the request.
On 08/19/2024 at 11:12 AM V1 (Administrator) stated, V10 (Medical Records) is in charge of medical
records. V10 is off today but V4 helps him. She is on her way up to answer any questions you may have.
On 08/19/2024 at 1:20 PM V1 stated, V10 started May 16, 2024. I did not receive a first request for medical
records for R4 either from family or their lawyers. In the interim before V10 started and after 04/29/2024 it
was just V4 doing medical records and if she received any requests she would send to our legal
department.
On 08/19/2024 at 11:15 AM V4 stated, family members have to be POA or guardian to request records.
They sign the release of information form. The resident also may sign if they are able to make that decision.
I haven't had any residents ask me for medical records recently. The ones I get are usually from insurance
companies. R4's attorney requested medical records for the family. We sent our attorney the medical
records requested for them to forward to the family's attorney. I think was a
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
145798
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
145798
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/20/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Countryside Nursing & Rehab Ctr
1635 East 154th Street
Dolton, IL 60419
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 0573
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
couple month's back. I can look through my email and verify. The family did not request the medical records
through me, but I am not the only one that deals with medical requests. V10 also deals with these requests,
and he is not here today.
On 08/20/2024 at 9:26 am V1 Administrator forwarded an email from their legal team dated 08/19/2024
stating the following: I personally copied the chart and date stamped it - 6,151 pages. I keep trying to
dropbox it to the law office, but it is having some kind of technical difficulty and will not go through. I told the
law office I will try breaking it down into smaller pieces to see where the issue is. This really is for a lawsuit
and not for continuity of care.
On 08/19/2024 at 11:25 AM attempted to call V10 from medical records. No answer. Left message to call
facility back and ask to speak with surveyor. Notified administrator of above. No response.
Release of Medical Record Information Policy dated 02/2016 states:
Policy: It is the policy of this facility that a release of medical information will be in accordance with
applicable state rules and federal laws and regulations.
Responsibility: Administrator, Director of Nursing, Medical Records Coordinator, Nursing Staff, Social
Services Staff, Activity Director or Activities Staff, Therapist, Food Service Personnel Attending Physicians,
Consultants and Contract Services.
Release of Medical Information
4 a. The resident - Medical and personal records shall be immediately accessible to the resident or their
legal representative upon oral or written request following proper written authorization of the resident or
their legal representative. The resident will be encouraged to review the record in the presence of a
professional healthcare representative so that the record may be protected and when necessary,
terminology may be explained. If the resident has been declared legally incompetent, the resident's legal
representative may exercise the above right on the resident's behalf. The resident or legal representative
may receive a copy of the record within two (2) working days of the advanced notice to the facility, and at
the resident's expense in accordance with state regulations.
i.
Attorneys 1)
The resident's authorization must be obtained to release information to attorneys except the facility's
attorney in charge of a lawsuit, when one exists.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145798
If continuation sheet
Page 2 of 2
