Health inspection·December 13, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the Facility failed to ensure staff were encouraging COVID-19 positive residents to wear masks and ensure staff don proper personal protective equipment (PPE) to prevent the spread of COVID-19. This has the potential to affect all 63 residents living in the facility. Residents Affected - Many Findings include: 1. The COVID list documents R6 with an onset date of 12/2/2024. R6's Physician Order Sheet for 12/2024 documents a diagnosis of Other specified disorder of kidney and ureter, COVID 19 (12/2/2024), urinary tract infection, unspecified dementia. unspecified severity without behavior disturbances, psychotic disturbances, mood disturbances, GERD, Abnormal weight loss, hypoosmolality and hyponatremia, major depression, insomnia, hypothyroidism. depression, and essential hypertension. On 12/10/2024 at 8:44 AM, R6's Room has a tub of Personal Protective Equipment (PPE) outside of her door with a sign which documents, Droplet Precautions. The sign documents, Everyone must clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry or remove face protection before exit. R6's Minimum Data Set (MDS) dated [DATE] document R6 was severely impaired for cognition for decision making of activities of daily living. R6's Care Plan undated documents, (R6) is a wanderer/elopement risk related to dementia. (R6) has a behavior of pulling isolation sign off door while on isolation. On 12/10/2024 at 8:48 AM, R6 was lying in a bed (equipment surplus) that was on the B hallway. The bed was near the exit door. R6 was not wearing any mask. R6 was able to ambulate independently and exited the bed and then started walking down the hallway. No staff member approached R6 and or encouraged her to put on a mask. On 12/10/2024 at 4:01 PM, V1 (Administrator) stated the bed was surplus and they were in the process of removing the bed from the facility and it was not intended for any resident to lay on in the hallway. R6's Progress Notes dated 12/9/2024 at 3:26 PM, Note Text: Resident continues on isolation precautions r/t (related to) COVID+ status. No acute changes noted. No c/o (complaint of) cough/congestion noted. Resident restless at end of evening shift. Able to redirect without difficulty. Did upset (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 12/13/2024 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)