Three Springs Sr Living: Staffing Failures Exposed - IL
The records, covering shifts from July 21 through August 10, showed one nurse clocked in at 6 p.m. and remained the only licensed medical staff in the building until 6 a.m. A licensed practical nurse who worked those hours told inspectors she felt it was not safe. The facility's own infection prevention and wound care nurse said the same thing directly: one nurse on the night shift is not sufficient.
The facility does not use agency nurses, according to the wound care nurse. There was no backup.
The staffing problems ran through every shift, not just nights. Four certified nursing assistants interviewed by inspectors described a facility that has frequently operated with as few as three CNAs on the day shift caring for all 66 residents. Three of those four CNAs described the same consequence: when there aren't enough people, mechanical lift transfers get done with a single CNA handling equipment designed to require two.
One CNA said this happens all the time. Another said no nurses help out when the floor is short. A third said evening shift is even worse than days.
The administrator's response, as described by one CNA, was that it is not her problem if people call off.
When inspectors asked that administrator, identified in the report as V1, about shower records for two specific residents, she said she had nothing for either of them going back to June. No shower sheets for June. No shower sheets for July. Two full months.
The facility's policy requires residents to receive at least two showers per week. The Director of Nursing acknowledged to inspectors that documentation showing showers were completed was missing. When asked directly whether the gap was caused by short staffing, she said: "I don't know."
The administrator told inspectors she had started a quality assurance review on showers the previous week, after a nurse called her on a Friday to report that showers hadn't been done. The review began, in other words, after inspectors were already at the door.
A fourth CNA put it plainly: they just do the best they can because no managers come in and work when the facility is short. She added that the facility tells CNAs they are responsible for finding their own replacements if they can't come in. When staff refuse to cover a short shift, she said, there is supposed to be a nurse or CNA on call, but they refuse to come in.
The staffing policy on file at the facility, which inspectors noted is undated, states that the facility provides sufficient numbers of staff with the skills and competency necessary to provide care. It promises licensed nurses and CNAs available 24 hours a day, and RN coverage eight hours per day, seven days a week.
Thirteen documented overnight shifts, one nurse, 66 residents.
The inspection was conducted as a complaint survey, meaning someone had already raised concerns before inspectors arrived on August 11. The level of harm was cited as minimal harm or potential for actual harm, the lower end of the federal scale, though inspectors noted some residents were affected.
What that means in practice: residents who need two people and a mechanical lift to get out of bed are being moved by one CNA working alone. Residents are going weeks, apparently months, without showers and without anyone in management noticing until a nurse makes a phone call on a Friday. And every night, one nurse walks into a building with 66 people depending on her and no one else coming.
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: July 4, 2026 · Our methodology
THREE SPRINGS SR LIVING & RHAB in CHESTER, IL was cited for violations during a health inspection on August 13, 2025.
The records, covering shifts from July 21 through August 10, showed one nurse clocked in at 6 p.m.
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.