F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the Facility failed to respect end of life wishes for 1 of 3 residents (R2)
reviewed for advanced directives in the sample of 4.
Findings include:
R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including diabetes
mellitus type 2, chronic kidney disease stage 3, liver cirrhosis, heart failure, and chronic venous
hypertension.
R2's Undated Care Plan documents R2 has chosen DNR (Do Not Resuscitate) as advanced directives for
end-of-life plan.
R2's Progress Note by V12 (Social Services Director/SSD) on [DATE] documented R2 wished to be a DNR
with comfort focused care, and R2's IDPH Uniform Practitioner Order for Life-Sustaining Treatment
(POLST) Form was completed with R2 and sent to physician for signature.
R2's POLST Form signed by V13 (R2's Physician) on [DATE] documents, No CPR (Cardiopulmonary
Resuscitation): Do Not Attempt Resuscitation (DNAR).
R2's Physician Orders document [DATE] orders for both Full Code and DNR.
R2's Progress Note by V10 (Licensed Practical Nurse/LPN) on [DATE] at 5:20 AM documents (R2) was
found sitting in recliner without blood pressure or respirations. The Note documents (R2) was a full code
and was assisted onto the floor where CPR was started, and an ambulance was called.
R2's Progress Note by V10 (LPN) on [DATE] at 5:32 AM documents CPR was in progress with no
improvement when the ambulance arrived, and paramedics called (R2's) time of death.
On [DATE] at 9:25 AM, V10 stated she entered (R2's) room and found him unresponsive in the recliner. She
stated she checked (R2's) Code Status which was listed as Full Code on his admission records and Face
Sheet, then called out for other staff to help and initiated CPR which was done until the paramedics arrived
and pronounced (R2) deceased .
On [DATE] at 11:35 AM, during a confidential interview, V5 (Confidential Interview #2) stated she assisted
with R2's CPR for about ten minutes until the ambulance arrived. She stated she felt R2's ribs crack on the
first push down.
(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 3
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
10/29/2024
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 0578
Level of Harm - Minimal harm
or potential for actual harm
On [DATE] at 1:15 PM, V1 (Administrator) stated R2 was a Full Code initially on admission, then his Code
Status was clarified, and R2 was changed to a DNR. She stated R2's brother attempted to take him home,
but R2 returned to the Facility the same day and all his orders were reinstated, including the orders for both
Full Code and DNR. V10 (LPN) looked in R2's orders and saw Full Code and performed CPR not knowing
he had a POLST Form for DNR.
Residents Affected - Few
On [DATE] at 12:00 PM, V13 (R2's Physician) stated, Advances directives serve as guidelines so staff know
what to do (in end of life situations). (R2)'s physical health was deteriorating, but his cognition was intact,
and he was a DNR. He left the hospital as a DNR. He did not want to be in a nursing home.
The Facility's Advanced Directives Policy revised 12/2016 documents advance directives will be respected
in accordance with state law and facility policy. The Policy documents Advanced Directive is a written
instruction, such as a living will or durable power of attorney for health care, recognized by State law,
relating to the provisions of health care when the individual is incapacitated. The Policy documents Do Not
Resuscitate indicates that, in case of respiratory or cardiac failure, the resident legal guardian, health care
proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other
life-sustaining treatments or methods are to be used.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145497
If continuation sheet
Page 2 of 3
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
10/29/2024
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 0727
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on
a full time basis.
Based on interview and record review, the Facility failed to use the services of a Registered Nurse (RN) for
at least eight consecutive hours a day, 7 days a week. This has the potential to affect all 70 residents living
in the Facility.
Findings include:
The Facility's Nurse's Schedule does not document a RN was scheduled for at least eight hours on
10/12/24, 10/13/24, 10/19/24, or 10/20/24.
On 10/25/24 at 3:18 PM, V1 (Administrator) stated the Facility did not have a RN for at least eight hours on
10/12/24, 10/13/24, 10/19/24 or 10/20/24.
On 10/25/24 at 9:25 AM, V2 (Director of Nursing), stated there can be problems with staffing due to call offs
and the Facility is actively recruiting staff.
On 10/25/24 at 9:50 AM, V1 stated the Facility is trying its best to recruit nurses, but it is difficult in a rural
setting when the Facility does not use agency staffing.
On 10/29/24 at 8:50 AM stated the Facility does not have a policy on RN staffing and follows the federal
regulations.
The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 10/29/24
documents there are 70 residents living in the Facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145497
If continuation sheet
Page 3 of 3
