Three Springs Sr Living & Rhab
THREE SPRINGS SR LIVING & RHAB in CHESTER, IL — inspection on September 5, 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.
Inspection Findings
PM V11 (Medical Director) stated being the medical director he gets calls all the time if the primary
had recommended against it. On 9/1/2025 at 6:00 PM, V31 (Former Director of Nursing) during a
the Social Service Director (SSD) told the floor nurse to see if she could get an order from the physician for (R1) to discharge home. I assume they got the order from the Medical Director, but I cannot say one way or the other.
You will have to talk to the Social Service Director. I know I did not have anything to do with this and I did not click anything wrong on the drop-down box and/or clicked another doctor's name by mistake. On 9/1/2025 at 9:02 PM, V14 (RN) stated I was a brand-new RN that day straight out of school. I remember I was told to get a discharge order for (R1). I believe this was a few weeks ago. I also remember getting a call from (V1) later asking me if I got an order. I remember (R1's) daughter was here that day and picked her up. Am I in trouble? I am just trying to figure out what is going on. On 9/3/2025 at 1:39 PM, V3 (Primary Doctor) stated, I got a call from (the facility) and they asked me if I would discharge (R1) back home. I told them I did not feel like it was safe because (R1) was seeing ortho and they wanted her to have Physical therapy, and she was not done with her treatments.
They wanted her to get stronger. At that time (R1) was not weight bearing and she had steps at her house. (Facility) did not know anything about how she would get home, if anyone would be helping her, and if she was going to be alone. I did not feel it was safe for (R1) to go home, and therapy was in the process of working with her because she had steps at home. I told them not to discharge (R1) because I was not sure about her support system.
Then I find out later that they discharged her without my permission, and I am her doctor. (R1) went back home and they are lucky because she had a friend move in with her, but what if she would not have had a friend? I do not feel they should be able to release residents without my consent unless things are in place for the safety of the resident.
This could have been very bad just releasing someone without support.
The facility did not follow their protocols and again they did not know if (R1) was going to have 24/7 care at home like she would have at the nursing home. I did not feel it was safe, and home health does not provide 24/7 support so anything could have happened.
Again, I never cleared (R1) because things were not in place and without knowing things are in place and protocols in place these could easily have impacted (R1) in a negative way.
Thank goodness her friend moved in with her and was helping her out because this could have been bad.
The Discharge Policy with a revision date of December 2016 documents, The purpose of this procedure is to provide guidelines for the discharge process.
Why the discharge is necessary (i.e., closer to home, relatives, etc.,) (Note: If this information is not known, ask the supervisor about this information.) If the resident is being discharged home, ensure that resident and/or responsible party receive teaching and discharge instructions.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.