Countryside Nursing & Rehab Ctr
Inspection Findings
F-Tag F0559
F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice
before a change is made. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to follow their policy in notifying resident representative of a cognitively impaired resident of changing the resident's room for one (Resident R4) of three residents reviewed for resident rights in a sample of five.Findings include:Resident R4 is an [AGE] year-old-male admitted to the facility on [DATE REDACTED] with diagnosis including but not limited to Type 2 diabetes mellitus; Hypertensive heart disease without heart failure; Unspecified convulsions; Hyperlipidemia; Nutritional anemia; Bipolar disorder; Anxiety disorder; Delusional disorders; Insomnia; and Chronic obstructive pulmonary disease.According to Resident R4's MDS (Minimum Data Set) assessment dated [DATE REDACTED] under section C, Resident R4 has BIMS (Brief Interview of Mental Status) score of 11 indicating moderately impaired cognition. According to Resident R4's face sheet, Resident R1 is deemed not responsible for self and has assigned emergency contact/responsible party. According to facility census, Resident R4's room was documented on 09/15/2025 at 9:13 AM. On 09/30/2025 at 12:45 PM V5 (Restorative Director) said, couple of weeks ago, I spoke to V2 (Assistant Administrator) and mentioned that Resident R4 should be moved to another room. I didn't initiate the change of Resident R4's room though.On 09/30/2025 at 1:15 PM V1 (Administrator/Abuse Prevention Coordinator) said, in case of a resident room change, either Director of Nursing or Social Service Director notifies residents' emergency contact of the change. On 09/30/2025 at 2:03 PM V10 (Social Service Staff) said, I worked on 09/15/2025 but I'm not aware of Resident R4's change of room. If a resident has an emergency contact, we call the emergency contact and notify them of change of room. It is documented then in the resident's electronic health record.On 09/30/2025 at 2:22 PM V2 (Assistant Administrator) said, I changed Resident R4's room in the system on 09/15/2025 at 9:13 AM as I was notified by V5 (Restorative Director) that Resident R4 wanted to change the room. I was assisting with change of room. I spoke to Resident R4, she indicated she wanted to be in a different room, I took her then to the new room, Resident R4 liked it, and she stayed there. Normally, nurses or social service staff would notify the resident's emergency contact about the room change. I didn't notify Resident R4's family that day.The facility Room Changes policy dated November 2026 reads in part, Policy: To make room changes when requested by the resident or as may become necessary to meet the resident's medical and nursing care needs. Policy specifications:
- 3. Prior to the room change, the resident, his or her roommate (if any), and the resident's representative will
be provided with information concerning the decision to make the room change.
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
Event ID:
COUNTRYSIDE NURSING & REHAB CTR in DOLTON, IL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in DOLTON, IL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from COUNTRYSIDE NURSING & REHAB CTR or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.