Three Springs SR Living: Shower Neglect Violations - IL
The resident, who suffers from cerebral infarction and moderate cognitive impairment, had not received a single shower in July or August at Three Springs Sr Living & Rhab, federal inspectors found during an August complaint investigation.
Administrator V1 confirmed the facility had no documentation showing the resident received any showers during those months. Another resident's records showed only scattered showers in July — on the 4th, 15th, 18th, 22nd, and August 1st.
The breakdown stemmed from chronic understaffing that left basic hygiene care undone for days at a time.
"No administration staff help care for the residents when they are short staffed, and residents do not get showers on the days the facility does not have enough CNAs," one certified nursing assistant told inspectors on August 11.
Another CNA was more direct: "The facility does not have enough CNAs, and showers don't get done like they are supposed to."
Director of Nursing V2 acknowledged the scope of the problem when inspectors requested shower records. "She has no proof the showers were completed as there is missing documentation showing the showers were completed," the inspection report states.
The nursing director said facility policy requires residents to receive at least two showers per week. But Administrator V1 contradicted this, telling inspectors the facility "does not have a policy on the frequency of resident showers although they are supposed to offer each resident 2 showers per week."
The administrator only discovered the shower crisis the previous Friday when a nurse called to report that showers hadn't been completed. She immediately launched a quality assurance investigation.
"V1 stated she does not have any shower sheets for R2 nor R11 for June nor July," inspectors documented.
When asked directly whether the shower failures resulted from staffing shortages, the nursing director claimed ignorance. "I don't know," she replied.
The residents affected include people with serious medical conditions requiring consistent care. One resident's admission record shows diagnoses of cerebral infarction, intervertebral disc degeneration, sciatica, tremors, repeated falls, and urinary retention. This person depends entirely on staff for bathing assistance.
Federal regulations require nursing homes to ensure residents receive adequate personal hygiene care, including regular bathing. The violation carries minimal harm designation but affected multiple residents.
The inspection revealed a facility where basic care standards collapsed under staffing pressures, leaving vulnerable residents to go weeks without fundamental hygiene services. Missing documentation suggests the problem extended beyond the specific residents inspectors interviewed.
CNAs described a workplace where administrative staff provided no direct care support during staffing shortages, forcing remaining workers to choose which essential services to skip. Showers consistently lost out.
The administrator's admission that the facility lacks a written shower policy despite an informal expectation of twice-weekly bathing points to broader systemic failures in care standards and oversight.
For residents like the one who asked inspectors about shower timing, the consequences were immediate and visible. Greasy, unkempt hair represented just the outward sign of a care system that had abandoned basic dignity requirements.
The quality assurance investigation launched after the nursing supervisor's call suggests management remained unaware of the shower crisis until it reached breaking point. By then, residents had endured weeks without proper hygiene care.
Federal inspectors found a facility where understaffing had become an excuse for neglecting fundamental human needs, leaving residents to ask strangers when they might next receive basic care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Three Springs Sr Living & Rhab from 2025-08-13 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: June 20, 2026 · Our methodology
THREE SPRINGS SR LIVING & RHAB in CHESTER, IL was cited for neglect violations during a health inspection on August 13, 2025.
Administrator V1 confirmed the facility had no documentation showing the resident received any showers during those months.
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.