Countryside Care Center: Nurse Left Residents for Hours - IL
By the morning of the incident that triggered a federal complaint inspection, two residents had been sitting in distress for hours. Neither had been sent to the hospital. The nurse responsible for the entire building that night was the only nurse on duty.
The agency registered nurse, identified in inspection records only as V8, told inspectors on August 30 that his reasoning for not sending one of the residents, a man with COPD referred to as R9, to the hospital was straightforward. "They came to me about R9 not breathing well, but R9 had COPD for gosh sakes, so R9 was not going to be breathing well," he said. He acknowledged giving R9 a nebulizer treatment that morning but added, "I did not sign it out."
The second resident, R4, was described as severely confused. V8 told inspectors that R4's confusion was itself a reason not to worry about missed medications. "R4 was so confused, did anyone take into consideration that R4 probably does not remember getting his medications," he said. Then: "Honestly, does it really matter on medications if a dose, here or there, does get missed. As far as I am concerned, if I signed it, I gave it."
Federal inspectors rated the deficiency as causing actual harm to residents.
A day shift nurse told inspectors that V8 never took the medication cart up and down the hallway for the 6:00 a.m. medication pass, a round described as heavy. The nurse said V8 appeared to be deliberate about which residents he skipped. "I think that V8 was very strategic with certain residents depending on their cognition as far as not giving medications," the nurse said. Residents with impaired memory or awareness, the nurse suggested, were less likely to notice or report a missed dose.
The same nurse said she had reported the problem to the administrator, the former director of nursing, and the assistant director of nursing, repeatedly. Each morning, she said, she came in and cleaned up what V8 had left undone. "Those poor residents sat there for hours without V8 monitoring or helping them," she told inspectors.
The assistant director of nursing, V5, confirmed she had heard complaints from both staff and residents about V8 not doing his job. She said she was uncertain whether the director of nursing was still employed at the time, so she wasn't sure who was responsible for addressing the problem. She also told inspectors that V8 sometimes left the building entirely during his shift for lunch, which she said was not permitted. V8 was the sole nurse responsible for the entire facility on those nights.
The administrator, V1, told inspectors the facility had been aware that V8 was not performing his duties. Because he was placed through a staffing agency rather than hired directly, the facility's response was to flag him as "Do Not Rehire," which she described as equivalent to termination.
The regional ombudsman, V4, told inspectors she had already heard about the situation from residents before the inspection began. "I heard they had problems with a night shift nurse over there, from the residents," she said on August 29. "Something with medications and not sending people out to the hospital."
The facility's own assistant director of nursing said the staffing shortage was part of why V8 kept working there as long as he did. "We needed our third shifts covered and needed him still to come in," V5 said.
R4 and R9 were eventually sent to the hospital. The day shift nurses who found them that morning had not been there when the decision should have been made.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Countryside Care Center from 2025-09-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 1, 2026 · Our methodology
COUNTRYSIDE CARE CENTER in MACOMB, IL was cited for violations during a health inspection on September 3, 2025.
By the morning of the incident that triggered a federal complaint inspection, two residents had been sitting in distress for hours.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.