Inspection·September 5, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few did not see the discharge papers. I know my mom would not leave AMA (against medical advice) and would only leave the nursing home if they said it was safe for her to leave. She needed a lot of help back then but is healing and doing better now. On 8/29/2025 at 12:22 PM, R1 stated, I was in the nursing home for almost a month. One day a nurse told me I could go home. I don't know her name. I called (V13 R1's friend) to let her know because I needed a ride to get home. I was not supposed to put weight on my foot and was not supposed to do stairs. I have three stairs at my house, and I had to climb the stairs to get inside and go out. Then later that same night another nurse came back and told me no; the doctor had not signed off on the order so I could not be released and go home. Then the next morning another nurse said, yes, I could go home. I had an incision, so I was having dressings and stuff put on my ankle. My friend (V13) came the next day and then they said I could leave and (V13) took me home. But then (V13) had to stay with me and help me with my care. She also took me to my doctor's visit, helped me with the stairs, cooked and cleaned for me and helped with my bandages and dressing for my ankle. I would never leave without the doctor's permission. I just wanted to go home but again; I would not leave if the doctor thought I should stay. On 8/29/2025 at 12:32 V13 (R1's friend) stated, (R1) called me the night before and told me she was going to get to go home, and she needed me to drive her. Then later that same night she called me back and said it was a mix up and the doctor had not signed any orders, and she would not be going home. The next day I just went to check on her and see what was going on. We kept getting two or three different stories about when and/or if she could not go home. Finally, a nurse came in, I do not remember her name, and she said, ‘I am the nurse and if I say she can go home she can go home.' They said the doctor signed the order, so I drove (R1) home that day and then I helped her up the stairs by putting a chair on the step and putting my arms around her so she would not fall. She could not have gotten in the house by herself. I then had to move in with her to help her that day because she could not at that point take care of herself and I wanted to help her get back on her feet again. I helped with cleaning her wound and putting the bandage on, assisting her and taking her to all her doctor appointments, cooking and cleaning and laundry, everyday things that at that time she could not do. She is doing better now, she has her cast off, but she still has 3 wounds on her leg that have not healed. We go to the wound doctor tomorrow. On 8/29/2025 at 1:29 PM, V10 (Social Service Director) stated, that Friday (R1) was saying she wanted to go home. That morning during morning meeting we discussed (R1) wanting to leave and I asked the nurse to get an order for her because we did not have an order for (R1) to discharge. (V14 Registered Nurse/RN) put in for an order, but she did not actually obtain an order from the doctor for (R1) to go home. At that time, I thought (R1) did have an order and I provided home health with PT (physical therapy), nursing and OT (occupational therapy) for her. The nurse never made contact with the doctor for (R1) to discharge. (R1) discharged on 7/19/2025. (R1) was discharged without a doctor's order. The nurse (V14) was brand new and had just graduated from nursing school. V10 stated she set up appointments for home health for (R1) and she followed up the next week but nothing after that. R1's Social Service Notes dated 7/19/2025 at 10:59 AM, Discharge recap of stay gone over with resident. Resident will be followed by (home health) with PT (physical therapy) and OT (occupation therapy). Resident voiced no concerns. R1's Health Status Note dated 7/19/2025 at 11:07 AM, Note Text: Resident discharged home with meds (medicine) per family vehicle. (R1 did not leave the facility in a family vehicle). R1's Occupational Therapy notes dated 6/24/-7/18/2025 documents recommend patient in the facility due to environmental limitations (steps to enter both front/back of home and unable to install ramp due to close proximity of front of home to main road and back due to fridge/cabinets blocking ability install ramp) and need for physical assistance to ascend/descend (continued on next page) 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 09/05/2025 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)

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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. Event ID: Facility ID: 145497 If continuation sheet Page 3 of 3