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Complaint Investigation

Three Springs Sr Living & Rhab

September 3, 2025 · Chester, IL · 161 Three Springs Road
Citations 1
CMS Rating 2/5
Beds 83
Provider ID 145497
Healthcare Facility
Three Springs Sr Living & Rhab
Chester, IL  ·  View full profile →
Inspection Summary

THREE SPRINGS SR LIVING & RHAB in CHESTER, IL — inspection on September 3, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0689
Quality of Life and Care Deficiencies
Actual Harm

down on the ground.

Assisted resident to back and large bruise and swelling noted above right eye.

Resident alert and able to answer questions appropriately.

Resident c/o (complained of) pain to right hip area.

This nurse contacted (Physician) and received order to send to (Hospital) for evaluation. EMS (emergency Medical Service) services contact and arrived shortly.

Resident transferred to stretcher without incident and transported to hospital. R3's Hospital Records dated 8/28/2025 at 12:50 PM, documents, Patient sent from (Facility), reported she fell out of her wheelchair hitting her forehead.

Large purple hematoma noted above right eyebrow.

History of stroke with right side weakness aphasia.

The patient spilled forward out of the wheelchair and struck her forehead, baseball size swelling and ecchymosis over the forehead. On 8/28/2025 at 2:33 PM, R3 was sitting outside and has an abrasion to the front of her head in the middle of her forehead approximately 6 millimeters in length and 4 millimeters in width , a black eye with a darken circle area is present on her entire left eye with a small blackish area under part of her eye on the right side, only 1/4 of the eye is covered in a black streak. On 8/28/2025 at 3:45 PM, V8 (Licensed Practical Nurse/LPN) stated (V15 Corporate) came and got me because (R3) is on my hall.

She told me (R3) had fallen outside. (R3) is hard to understand and she does moan out loud, really loud when she needs something because she can't communicate very well. I think (V12 LPN) took her outside. I am not sure why she did not stay with her. (R3) likes to go outside and we have several residents that like to go outside but they are more alert than (R3). We are supposed to stay with (R3) when she is outside. I just got call from the hospital. 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. On 8/28/2025 at 3:53 PM, V12 (LPN) stated, (R3) cannot walk on her own and she uses a wheelchair.

You have to really pay attention to (R3) to know what she wants. (R3) moans a lot when she wants something.

She had a stroke.

She just recently lost her husband; they were roommates here together. (R3) was in the dining room today, and she was wanting her cigarettes, and she only had a small cigarette left so I took her outside.

She likes to go outside.

She only had a part of a cigarette and after she finished, (R3) did not want to come back in. (R3) has never thrown herself on the floor before, and I did not lock her wheelchair. I did not bring her back in because (R3) did not want to come back. I am not sure if she needed supervision or if she could stay outside unsupervised. I don't know. 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.

The Facility Fall Policy with a revision date of March 2018 documents, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk and causes to try to try to prevent the resident from falling and try to minimize complications from falling.

The Facility Smoking Policy with a revision date of July 2017 documents, Any resident with restricted privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times when smoking.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CHESTER, IL, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from THREE SPRINGS SR LIVING & RHAB or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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