Three Springs Sr Living & Rhab
Inspection Findings
F-Tag F0627
F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
steps, although patient unexpectedly discharged home with friend intermittent assistance. Unsure extent of patient's friend's ability to provide physical lifting assistance. On 8/22/25 at 10:02 AM, V7 (Licensed Practical Nurse/LPN) stated a physician's order is needed to discharge a resident. V7 denied releasing a resident without a physician's order. On 8/22/25 at 10:15 AM, V8 (LPN) stated a physician's order is needed to discharge a resident. V8 denied releasing a resident without a physician's order. On 8/22/25 at 10:22 AM, V1 (Administrator) stated that V3 (Primary Care Physician) would not sign the release therefore V11 (Medical Director) signed the discharge release. The Director of Nursing made a mistake and clicked (V3's) name in the dropdown box instead of the Medical Director's name. On 8/25/25 at 3:04 PM V11 (Medical Director) stated being the medical director he gets calls all the time if the primary cannot be reached.
However, he did not recall (Resident R1) and would not release/discharge a resident if the primary was against it.
V11 also stated he would not release/discharge a resident if physical therapy had recommended against it.
On 9/1/2025 at 6:00 PM, V31 (Former Director of Nursing) during a phone interview stated, I did not take over as the Director of Nursing until 7/17/2025. I was told that the Social Service Director (SSD) told the floor nurse to see if she could get an order from the physician for (Resident 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 (Resident 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 (Resident 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 (Resident R1) back home. I told them I did not feel like it was safe because (Resident 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 (Resident 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 (Resident 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 (Resident 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. (Resident 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 (Resident 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 (Resident R1) because things were not in place and without knowing things are in place and protocols
in place these could easily have impacted (Resident 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.
Event ID:
Facility ID:
If continuation sheet
THREE SPRINGS SR LIVING & RHAB in CHESTER, IL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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.