Health inspection·September 3, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to supervise a moderately impaired resident with a history of stroke. R3 was left unattended outside and fell from the wheelchair for 1 of 3 residents (R3) reviewed for falls in the sample of 6. This failure resulted in R3 being sent to the hospital after sustaining a black eye and bruising to her forehead from the fall. Findings include: R3's Physician Order Sheet for August 2025 documents diagnosis of atherosclerotic heart disease, cerebral infarction due to thrombosis of left middle cerebral artery, unsteadiness on feet, weakness, need for assistance with personal care, lack of coordination, other abnormalities of gait and mobility, muscle weakness, hemiplegia and hemiparesis following cerebrovascular disease affecting unspecified side. R3's Minimum Data Set (MDS) dated [DATE] document she is moderately impaired for cognition for activities of daily living. She has impairment on one side on both her upper and lower extremities and uses a wheelchair. For transfers she requires a Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed -Helper does ALL the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. R3's Care Plan: dated 4/10/2025 documents, the resident has hemiplegia/hemiparesis. The Care Plan with a created date of 1/5/2025 documents, The Resident has impaired cognitive function/dementia or impaired thought processes, the resident is on anticoagulant therapy. The resident has an ADL (activities of daily living) Self Care Performance Deficit, start date 1/5/2024. For Falls with a created date of 7/17/2025, (R3) is at risk for falls related to history of stroke with hemiplegia and hemiparesis and weakness. The Care Plan with a start date of 4/10/2025 also documents the resident has impaired visual function. R3's Smoking assessment dated [DATE] documents, Resident is a supervised smoker. Resident has to be reminded to hand staff her cigarette to put it out. Resident only smokes occasionally and only a few drags off cigarette. R3's falls Risk assessment dated [DATE] documents R3 was at risk for falls. On 8/28/2025 at 12:18 PM, R3 was sitting near the entrance of the facility in her wheelchair. R3's wheelchair brakes were locked, and R3 was rocking back and forth, as an attempt to propel forward. R3 was moaning and was slumped in the chair. There was another resident outside as well but with her back to her and that resident (R4) was talking on the phone. There were no staff outside. The double doors were shut, and no staff were monitoring any resident. R3 was moaning repeatedly and rocking back and forth. Surveyor approached R3 and asked R3 if she needed anything, but she was not alert and was just moaning and then she leaned forward in her wheelchair, slipped out and hit her head on the concrete as fell out of the chair. R3 sustained abrasions on her knees and a large baseball size swelling on her forehead. Surveyor ran inside the building to alert staff (V1 Administrator) and to get assistance for R3. R3's Progress Notes dated 8/28/2025 at 12:20 PM, Note Text: This nurse was notified by staff that resident was found on the ground at the front entrance/patio area. Resident was found lying face (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 2 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 09/03/2025 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)