Three Springs Sr Living: Seizure Med Delays - IL
She did the best she could, she later told inspectors. But she never called the doctor.
The resident at the center of the complaint, identified in inspection records as R6, has lived with a seizure and epilepsy diagnosis for years. His wife told staff he is particular about his medications, concerned if they are even a minute late. His orders called for seizure medication at 8 AM and 8 PM. On the day the facility called in the traveling nurse, neither window was met.
The following day, R6's wife told another nurse at the facility that her husband had been experiencing seizure activity, and that the day before he had received his seizure medication late. When that nurse, a licensed practical nurse identified in the report as V9, went to check on R6, she observed him making small twitching movements. She sent him out.
The medical doctor who treats R6, identified as V19, spoke with inspectors on November 17, 2025. He was direct. R6 has had this diagnosis for years, he said, and it is important that his orders are being followed. Missing or delaying his medications could cause R6 to have seizures and would not be good.
The facility's own pharmacist, V22, was interviewed the following morning. The pharmacist noted something else: the facility's records did not list a diagnosis of seizures or epilepsy for R6, only a notation for convulsions. The pharmacist said that diagnosis would support the medications being prescribed, but flagged the discrepancy. On the core question, the pharmacist was measured but clear. Taking seizure medications late may or could contribute to a seizure, the pharmacist said. Whether it rises to a significant medication error would depend on whether a seizure occurred. If a seizure occurred, then yes.
One had.
The nurse who made the hour-long drive to cover the short-staffed shift, identified as V18, told inspectors she knew the medications were late by the time she arrived and began passing them. She said she did the best she could under the circumstances. She also acknowledged she did not notify the physician that the medications had been delayed. A lot of medications were late that day, she said.
Three Springs has a medical policy, last revised in 2012, stating that medications shall be administered in a safe and timely manner and as prescribed. The policy also requires that if a drug is given at a time other than its scheduled time, the nurse administering it must mark the medication administration record accordingly. Inspectors cited the facility for a violation at the level of minimal harm or potential for actual harm.
R6's wife had already noticed. She was the one who reported the seizure activity to staff. She was the one who told them her husband had received his medication late the day before. She had been telling staff for some time that he is particular about the timing, that even a minute matters to her.
She was right.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Three Springs Sr Living & Rhab from 2025-11-18 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 21, 2026 · Our methodology
THREE SPRINGS SR LIVING & RHAB in CHESTER, IL was cited for violations during a health inspection on November 18, 2025.
She did the best she could, she later told inspectors.
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.