Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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
(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 3
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
02/13/2025
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 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.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145798
If continuation sheet
Page 2 of 3
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
02/13/2025
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 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
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145798
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
FAQ · About this visit
Common questions about this visit
What happened during the February 13, 2025 survey of COUNTRYSIDE NURSING & REHAB CTR?
This was a inspection survey of COUNTRYSIDE NURSING & REHAB CTR on February 13, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at COUNTRYSIDE NURSING & REHAB CTR on February 13, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement policies and procedures to prevent abuse, neglect, and theft."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.