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
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 (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 (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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