Cycle 1
Health 2024-06-14 · Fire 2024-06-14
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Chester, IL
Three Springs Sr Living & Rhab
3-star overall rating with 4-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
161 Three Springs Road, Chester, IL
(618) 826-3210
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
83
Certified beds
Average residents
65
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Wlc Management Firm
Operator or chain grouping
Approved since
1984-09-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.15
Registered nurse staffing
LPN hours / resident day
0.78
Licensed practical nurse staffing
Aide hours / resident day
1.80
Nurse aide staffing
Weekend hours
2.66
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.0
0.2 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.1 |
2.3
0.8 pts worse
|
1.8
1.3 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.0% |
89.6%
3.4 pts better
|
93.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.7% |
91.6%
1.9 pts worse
|
95.5%
5.8 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
3.3%
1.6 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 4.2% |
50.3%
46.1 pts better
|
11.4%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.3% |
6.5%
2.2 pts better
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.8% |
18.5%
1.3 pts worse
|
19.6%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 14.1% |
22.8%
8.7 pts better
|
16.7%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.4% |
0.1%
0.3 pts worse
|
0.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 34.5% |
17.2%
17.3 pts worse
|
16.3%
18.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.7% |
15.0%
12.7 pts worse
|
14.9%
12.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
1.1%
0.1 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.7% |
1.7%
1 pts worse
|
1.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.5% |
21.3%
4.2 pts worse
|
19.8%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
5.2%
0.2 pts better
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 66.9% |
68.8%
1.9 pts worse
|
81.7%
14.8 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
2.3%
0.4 pts better
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 40.9% |
63.0%
22.1 pts worse
|
79.7%
38.8 pts worse
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-13 · Fire 2023-09-13
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-08-19 · Fire 2022-08-19
2 health deficiencies
Top issue: Environmental (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-06-14
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-07-05
E · Potential for more than minimal harm
2024-06-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-05
E · Potential for more than minimal harm
2024-06-14
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-07-05
F · Potential for more than minimal harm
2023-09-13
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-09-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-09-13
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-09-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-09-13
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-09-13
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-09-27
E · Potential for more than minimal harm
2023-09-13
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-09-27
E · Potential for more than minimal harm
2023-09-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-09-27
F · Potential for more than minimal harm
2022-08-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-19
E · Potential for more than minimal harm
2022-08-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-09-19
E · Potential for more than minimal harm
2022-08-19
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-09-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-12-03
D · Potential for more than minimal harm
2025-09-05
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-09-22
G · Actual harm
2025-09-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-18
E · Potential for more than minimal harm
2025-08-13
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-08-21
E · Potential for more than minimal harm
2025-08-13
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-08-21
D · Potential for more than minimal harm
2025-08-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-18
F · Potential for more than minimal harm
2024-12-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-30
F · Potential for more than minimal harm
2024-11-19
F727 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2024-11-27
F · Potential for more than minimal harm
2024-11-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-27
E · Potential for more than minimal harm
2024-11-19
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-11-27
F · Potential for more than minimal harm
2024-10-29
F727 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2024-11-19
D · Potential for more than minimal harm
2024-10-29
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2024-11-05
F · Potential for more than minimal harm
2024-06-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-06-14
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-07-02
B · Minimal harm
2024-06-14
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2024-07-02
B · Minimal harm
2023-09-13
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2023-09-27
D · Potential for more than minimal harm
2022-08-19
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-08-31
B · Minimal harm
2022-08-19
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2022-09-07
Penalties and ownership
What sits behind the stars
Ownership
Stout, Scott
5% Or Greater Direct Ownership Interest · Individual
Stout, Scott
Operational/Managerial Control · Individual
Stout, Scott
Corporate Officer · Individual
Wlc Management Firm LLC
Operational/Managerial Control · Organization
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4-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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#3
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3-star overall rating with 5-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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