Three Springs Sr Living: Resident Left Alone, Falls - IL
The resident, identified in inspection records as R3, had a history of stroke with right-side weakness and aphasia. On August 28, 2025, she was transported to the hospital with a baseball-sized purple hematoma above her right eyebrow, an abrasion on the center of her forehead roughly six millimeters long, and a black eye covering her entire left eye. A darkened streak ran under part of her right eye as well.
The nurse who took her outside, identified as V12, told inspectors what happened plainly. "She only had a part of a cigarette and after she finished, R3 did not want to come back in," V12 said. "I did not bring her back in because R3 did not want to come back." V12 also acknowledged she had not locked the wheelchair before leaving. When asked whether the resident needed supervision outside, V12 said: "I'm not sure if she needed supervision or if she could stay outside unsupervised. I don't know."
Another nurse on the hall, V8, told inspectors the expectation was clear. "We are supposed to stay with R3 when she is outside," V8 said. "I am not sure why she did not stay with her. R3 is hard to understand and she does moan out loud, really loud, when she needs something because she can't communicate very well."
V12 also told inspectors that R3 had recently lost her husband. They had been roommates at the facility together.
The facility is disputing the citation. Inspectors classified the violation as causing actual harm to one of a few residents affected.
R3 was transferred to a stretcher and transported to the hospital. Her hospital records confirmed she was sent from the facility after falling from her wheelchair and striking her forehead.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Three Springs Sr Living & Rhab from 2025-09-03 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
THREE SPRINGS SR LIVING & RHAB in CHESTER, IL was cited for violations during a health inspection on September 3, 2025.
The resident, identified in inspection records as R3, had a history of stroke with right-side weakness and aphasia.
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.