Three Springs SR Living: Fall Leaves Resident with Head Injury - IL
On August 28, 2025, a licensed practical nurse at Three Springs Senior Living and Rehabilitation took a stroke survivor, identified in inspection records only as R3, outside to finish a cigarette. R3 used a wheelchair, could not walk on her own, and had significant difficulty communicating. Her speech had been affected by the stroke. When she wanted something, she moaned — loudly — because words were largely unavailable to her.
The nurse, identified as V12, said R3 had only a small piece of a cigarette left when she brought her outside. After R3 finished it, she didn't want to come back in. So V12 left her there.
"I did not bring her back in because R3 did not want to come back," V12 told inspectors that afternoon. "I am not sure if she needed supervision or if she could stay outside unsupervised. I don't know."
At some point after V12 left, R3 fell forward out of her wheelchair and struck her forehead on the ground.
When staff found her, R3 was on the ground. A large bruise and swelling had already formed above her right eye. She was alert and able to answer questions, but she complained of pain in her right hip. The nurse on duty called a physician and got an order to send her to the hospital. EMS arrived and transported her.
Hospital records from that afternoon document what they found: a baseball-sized swelling and bruising over her forehead, a large purple hematoma above her right eyebrow. A notation described her as having spilled forward out of the wheelchair and struck her forehead. By 2:33 that afternoon, as she sat outside the hospital, staff documented an abrasion to the front of her head approximately 6 millimeters long and 4 millimeters wide, a black eye covering her entire left eye, and a dark streak under part of her right eye.
V12 told inspectors she had not locked R3's wheelchair before leaving her.
Another nurse, V8, learned about the fall when she got a call from the hospital. She told inspectors that R3 was on her hall, that R3 was hard to understand, and that staff were supposed to stay with R3 when she went outside. "We are supposed to stay with R3 when she is outside," V8 said. "I am not aware of her having any previous falls. She has never had behaviors and/or threw herself on the ground that I am aware of."
V12 knew some version of this. She acknowledged that R3 needed supervision for smoking. She said R3 loved going outside. She said she understood R3's communication challenges — that R3 moaned when she wanted something, that you had to really pay attention to know what she was asking for. She also mentioned, in the same conversation with inspectors, that R3 had recently lost her husband. They had been roommates at the facility together.
What V12 said she didn't think about was whether any of that meant R3 needed someone to stay with her once the cigarette was gone.
"I know she does need supervision for the cigarettes, but I did not think about it for being outside because she loves to go outside," V12 said.
The facility's own smoking policy, last revised in July 2017, states that any resident with restricted privileges requiring monitoring must have direct supervision from a staff member, family member, visitor, or volunteer at all times when smoking. The fall policy, revised in March 2018, calls for staff to identify interventions based on each resident's specific risks and to implement them.
Federal inspectors cited the facility for failing to protect R3 from an accident that supervision could have prevented. The citation was tagged at a level of actual harm. The facility is disputing it.
R3 had a stroke. She had lost her husband. She could not walk. She could barely speak. On a late August afternoon, she wanted to stay outside a little longer, and the person responsible for her care decided that wanting something was the same as being safe doing it.
She was on the ground before anyone came back.
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.
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: August 5, 2026 · Our methodology
THREE SPRINGS SR LIVING & RHAB in CHESTER, IL was cited for violations during a health inspection on September 3, 2025.
R3 used a wheelchair, could not walk on her own, and had significant difficulty communicating.
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.