Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to attempt Gradual Dose Reductions on psychotropic
medications for 1 of 3 residents (R23) in a sample of 10.
Findings include:
R23's face sheet from EHR (electronic health record) dated on 6/14/024 noted that R23 was admitted on
[DATE] with diagnoses of: Chronic obstructive pulmonary disease, unspecified, cerebral infarction,
unspecified, encounter for palliative care, type 2 diabetes mellitus without complications; unspecified
psychosis not due to a substance, insomnia, unspecified, Alzheimer's Disease, unspecified dementia, with
psychotic disturbance, specified anxiety disorders, major depressive disorder, single episode, essential
hypertension, chronic ischemic heart disease, gastroesophageal reflux disease without esophagitis,
hypoxemia, chronic pain acute kidney failure, headache, diverticulosis of both small and large intestine
without perforation or abscess without bleeding, benign prostatic hyperplasia without lower urinary tract
symptoms.
R23's Minimum data set (MDS) dated [DATE] scored the brief interview of mental status (BIMS) at a 13,
cognitively intact. The E section noted to report R23's overall presence of behavioral symptoms is a 0.
R23's care plan dated 6/2/2023 noted R23 has impaired cognitive function and impaired thought processes
r/t Alzheimer's, Dementia with confusion; 1) Administer Alzheimer's medication as ordered. Monitor for side
effects and effectiveness. R23 uses psychotropic medications r/t (related to) depression. 1) Administer
psychotropic medications as ordered by physician. Monitor for side effects and effectiveness Q-shift (every
shift). 2) Consult with pharmacy, MD to consider dosage reduction when clinically appropriate at least
quarterly.
R23's POS, (physician order sheet) dated 6/14/2024, noted Buspar 5 MG PO ( by mouth) twice a day;
Donepezil HCL 10 MG PO at sleep, Duloxetine HCL 60 MG twice a day, Ativan 0.5 MG PO mornings,
Ativan 1 MG PO twice a day, Risperidone 0.5 MG in morning, Zoloft 50 MG in morning, Trazadone 100 MG
PO at sleep, Vicodin 10-325 MG PO six times a day, Morphine Sulfate 0.5/20 MG PO every 2 hours when
necessary, melatonin 5 MG at sleep.
On 6/14/2025 at 2:30 PM, R23 is a 76 Y/O alert and oriented to person, place, and time. R23 voiced no
concerns at the time of interview. Stated that he takes his medications when the nurse gives them to him.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 5
Event ID:
145497
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145497
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/14/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Three Springs Sr Living & Rhab
161 Three Springs Road
Chester, IL 62233
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
R23's EHR noted pharmacy consults on medications of Ativan 1/31/2024, Trazadone 2/28/2024, Duloxetine
3/28/2024, Risperidone 4/29/2024, Zoloft 5/28/2024, Ativan 6/6/2024 with no new orders. No behavior
documentation noted on MAR (medication administration record) for each month of January, February,
March, April, May and June.
Residents Affected - Few
R23's OBRA Screen dated 7/1/2022 identifies R23 as having no mental illness noted.
On 6/14/2024 at 1:40 PM V2 (Director of Nurses/DON), stated that she and V1 (Administrator) will be
starting a committee to train the nursing staff on behavior monitoring and documentation. She stated that
she does expect to be collaborating with the pharmacy, nursing staff, and physician. She stated the
pharmacy recommendations for the residents on psychotropic medication reduction will be discussed with
the physician.
The Facility's Policy titled MED-PASS, Inc. (Revised December 2016) documents:
Antipsychotic medications may be considered for residents with dementia but only after medical, physical,
functional, psychological, emotional psychiatric, social, and environmental causes of behavioral symptoms
have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible
dosage for the shortest period and are subject to gradual dose reduction and re-review.
1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for
which they are indicated and effective.
2. The Attending Physician will identify, evaluate, and document, with input from other disciplines and
consultants as needed, symptoms that may warrant the use of antipsychotic medications.
3. Residents who are admitted from the community or transferred from a hospital and who are already
receiving antipsychotic medications will be evaluated for the appropriateness and indications for use. The
interdisciplinary team will: a. Complete PASRR screening (preadmission screening for mentally ill and
intellectually disabled individuals), if appropriate; or b. Re-evaluate the use of the antipsychotic medication
at the time of admission and/or within two weeks (at the initial MDS assessment) to consider whether the
medication can be reduced, tapered, or discontinued.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145497
If continuation sheet
Page 2 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145497
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/14/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Three Springs Sr Living & Rhab
161 Three Springs Road
Chester, IL 62233
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review, the Facility failed to store foods in a manner that
prevents foodborne illness. This has the potential to affect all 66 residents living in the Facility.
Residents Affected - Many
Findings include:
On 6/11/24 at 9:17 AM, there were crumbs on the bottom shelf of the serving counter and the bottom shelf
of the food preparation area. The oven handles were sticky to the touch.
On 6/11/24 at 9:20 AM, the standing refrigerator had a plastic bag with julienned zucchini that was not
labeled or dated. There was a container holding various colored cups of individual liquids that were not
labeled or dated. There were two opened containers of whipped cream with frosting tips that were lying on
the shelf and were not re-wrapped or dated upon opening. There was a container of unlabeled fruit that was
dated 6/2/24.
On 6/11/24 at 9:20 AM, the deep freezer in the dry storage room contained a package of chicken breasts
that had been opened, but were not resealed upon opening, leaving the contents open to air. The package
was not labeled or dated upon opening.
On 6/11/24 at 9:23 AM, the standing refrigerator in the dry storage room contained two individual
Styrofoam containers of salad with no label or date.
On 6/7/24 at 9:25 AM, there was a large container of sanitizer for a low temperature dish machine that was
placed directly on the floor of the dry storage room. It was touching the bottom rack of a shelf with a can of
cherry pie filling and a can of baked beans directly next to it.
On 6/11/24 at 9:34 AM, in the break room refrigerator there were three plastic bags labeled R64. One was
labeled toffee, but the other two package contents were not documented. None of the bags were dated. The
freezer had brown smears covering a majority of the bottom shelf. The refrigerator had red spills on the
bottom shelf.
On 6/14/24 at 9:05 AM, in the standing refrigerator there was a container of pasta salad that was not
labeled or dated. V10 (Dietary Manager) stated she will get rid of it because she does not know how long it
has been in there. She stated she expects all items to be labeled and dated.
The Facility's Food Storage (Dry, Refrigerated, and Frozen) Policy dated 2016 documents, Food shall be
stored in a clean, dry area, free from contaminants. All food items will be labeled. The label must include
the name of the food and the date by which it should be sold, consumed, or discarded. Discard food that
has passed the expiration date, and discard food that has been prepared in the facility after seven days of
storing under proper refrigeration. Leftover contents of cans and prepared food will be stored in covered,
labeled and dated containers in refrigerators and/or freezers.
The Facility's Labeling and Dating Foods (Date Marking) Policy dated 2016 documents, All foods stored will
be properly labeled according to the following guidelines. Date marking for freezer storage food items
documents, Once a package is opened, it will be re-dated with the date the item was opened and shall be
used by the safe food storage guidelines or by the manufacturer's expiration date.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145497
If continuation sheet
Page 3 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145497
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/14/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Three Springs Sr Living & Rhab
161 Three Springs Road
Chester, IL 62233
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Prepared food or opened food items should be discarded when: The food item does not have a specific
manufacturer expiration date and has been refrigerated for 7 days; The food item is leftover for more than
72 hours; The food item is older than the expiration date.
The Facility's Long-Term Care Facility Application For Medicare And Medicaid dated 6/11/24 documents
there are 66 residents living in the Facility.
Event ID:
Facility ID:
145497
If continuation sheet
Page 4 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145497
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/14/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Three Springs Sr Living & Rhab
161 Three Springs Road
Chester, IL 62233
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0912
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single
resident rooms.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation and interview, the facility failed to provide 80 square feet of floor space per resident bed for 50
residents (R2, R3, R4, R5, R6, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R21, R22, R23, R24,
R26, R27, R28, R29, R32, R35, R37, R38, R41, R42, R45, R46, R47, R49, R51, R52, R53, R55, R58,
R58, R59, R60, R61, R62, R63, R64, R167, R168, R169, R217, R267) reviewed for room size in the
sample of 63.
Findings include:
A Hall Rooms 1 - 12 are all Medicaid certified and provide 75 square feet per bed.
B Hall Rooms 1 - 6 and 8 are all Medicaid certified and provide 75 square feet per
Bed.
C Hall Rooms 1 -8, 10 and 12 are all Medicaid certified and provide 75 square feet
per bed.
D Hall rooms [ROOM NUMBERS] are Medicaid certified and provide 77 square feet per bed.
On 06/14/24 at 11:00 AM, V17 (Maintenance Director) measured the rooms and verified that R2, R3, R4,
R5, R6, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R21, R22, R23, R24, R26, R27, R28, R29,
R32, R35, R37, R38, R41, R42, R45, R46, R47, R49, R51, R52, R53, R55, R58, R58, R59, R60, R61,
R62, R63, R64, R167, R168, R169, R217, R267 all reside in those rooms.
Observations made throughout the survey from 06/11/24 through 06/14/24 demonstrate no concerns or
complaints vocalized by residents in relation to waivered room size.
On 06/14/24 at 1:30 PM, V4 (Vice President of Operations) stated there have been no changes to the
historical measurements and accuracy of the facility's waivered resident room numbers and certifications.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145497
If continuation sheet
Page 5 of 5
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F912 - Measure at least 80 square feet per resident in multiple resident
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
FAQ · About this visit
Common questions about this visit
What happened during the June 14, 2024 survey of THREE SPRINGS SR LIVING & RHAB?
This was a inspection survey of THREE SPRINGS SR LIVING & RHAB on June 14, 2024. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at THREE SPRINGS SR LIVING & RHAB on June 14, 2024?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiatin..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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