Health inspection·February 13, 2025

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to follow the facility policy on conducting background and fingerprint checks for four employees (V11, V12, V13, V14) at time of hire. This failure has the potential to affect 144 residents currently residing in the facility. Residents Affected - Many Findings include: Per census report there are 144 residents currently residing in the facility. On 2/10/2025, at 2:10 PM, V3 (Human Resource) brought requested files to surveyor for review. V3 stated, what is in the file is what I have. I do not have the background checks for V11 (Maintenance) or the Illinois Sex Offender check for V13 (Certified Nursing Assistant). V14 (Maintenance) does not work here he is on the termination list with a termination of employment date of 4/18/2023. Regarding V12 (Activity Aide), I just checked the IDPH website, and his application shows not yet determined. Fingerprints for V12 were done 8/13/2024 and his hire date was 5/16/2024. On 2/11/2025, at 9:25 AM, V3 Human Resource stated regarding V14 we looked in the old records and could not find any of the background checks for him. For V13, I ran the Illinois Sex Offender check yesterday (2/10/2025) as I could not find it in her file. Regarding V11, I did not have any of the background checks in the file, so I ran them yesterday (2/10/2025). Nothing came up in the search for V11 on the IDPH website so I entered his information in the system so he can get fingerprinted. For V12, he said he had the fingerprint receipt but could not find it. I told him he had to go again, and he said he would. His supervisor is aware. On 2/11/2025, at 12:58 PM, V3 Human Resource stated, applicants come in and fill out the application, then receptionist asks for social security card and driver's license and adds it to the paperwork. While they are doing the application she checks the registry. After the application is given to her, she forwards it to the department head. The department head decides if they want to give them an interview. If they decide to hire, they keep the application until interview, then checks references. They do the interview and if hired we keep the application packet and set up orientation date. This is usually on Thursdays. When they come in for orientation they get an orientation packet. I put them in IDPH website the same day as orientation. If they need fingerprints, we send them for fingerprints. If for some reason they don't have one of the id's they are made aware to bring to orientation and a sticky note is put on the front of the folder for me to follow up. Normally I just wait for administrator to forward the email from IDPH letting us know if they are eligible to work after fingerprints are processed. In the meantime, staff is allowed to work until determined ineligible. On 2/11/2025, at 1:56 PM, V1 Administrator stated my expectation for my staff is that background checks are done in a timely manner according to regulations. In a perfect world all background checks Page 1 of 3 145798 145798 02/13/2025 Countryside Nursing & Rehab Ctr 1635 East 154th Street Dolton, IL 60419

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many should be done prior to hire. I could not tell you why the indicated background checks were not done prior to hire as I was not here, and it was a different HR person. My current HR person could not even explain it to me. I am told the results that come after fingerprinting come to the administrator email. I did check it and did not find the email regarding V11 and V12. I have seen delays in the past but not for months. If they don't come in a few weeks, we should be following up on them. In my opinion HR should not file the folder until everything comes back. My current HR was never sent for training, so I have already reached out to a sister building to get trained on all of this. Review of facility employee documents: V11 Date of Hire: 4/20/2023 V12 Date of Hire: 5/16/2024 V13 Date of Hire: 1/16/2025 V14 Date of Hire: 9/20/2022 Background Screening Investigations Policy (undated) documents the following: Policy Statement Our facility conducts employment background screening checks including but not limited to criminal background checks, sex offender database, OIG exclusion database, reference checks and criminal conviction investigation checks on individuals making application for employment with our facility. Policy Interpretation and Implementation 1. The Personnel/Human Resources Director, or other designee, will conduct employment background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law) on persons making application for employment with this facility. Such investigation will be initiated in accordance with state regulatory guidelines pertaining to employment or offer of employment. 2. For any individual applying for a position as a Certified Nursing Assistant, the state nurse aid registry will be contacted to determine if any findings of abuse, neglect, mistreatment of individuals, and/or theft of property have been entered into the applicant's file. 3. For any licensed professional applying for a position that may involve direct contact with residents, his/her respective licensing board will be contacted to determine if any sanctions have been assessed against the applicant's license. 4. 145798 Page 2 of 3 145798 02/13/2025 Countryside Nursing & Rehab Ctr 1635 East 154th Street Dolton, IL 60419

F 0607 Level of Harm - Minimal harm or potential for actual harm Should the background investigation disclose any misrepresentation on the application form or information indicating that the individual has been convicted of abuse, neglect, mistreatment of individuals, and/or theft of property, or other exclusions as identified by state or federal requirements, the applicant will not be employed and/or will be terminated for employment. Residents Affected - Many 145798 Page 3 of 3