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
Chain footprint
17 facilities
Chain averages 3 overall / 4 health / 1 staffing / 1 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.15
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.80
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
2.73
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
0.92
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
2.66
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.11
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.17
CMS adjusted RN staffing hours
Adjusted total hours
3.17
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
11,352
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.13
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
3.43
Performance 6.81% · Measure score 3.43 · Achievement 3.43 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
0
Baseline 4.04 hours · Performance 2.91 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.16% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 46 · Observed rate 6.52% · Lower 95% interval 6.19% |
| Discharge to community | 29.46% |
50.57%
21.1 pts worse
|
Worse than the National Rate · Eligible stays 37 · Observed rate 16.22% · Lower 95% interval 19.87% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 90.48% |
95.27%
4.8 pts worse
|
Numerator 19 · Denominator 21 |
| Falls with major injury | 4.76% |
0.77%
4 pts worse
|
Numerator 1 · Denominator 21 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 21 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.81% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 26 · Observed rate 3.85% · Lower 95% interval 3.1% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 67 |
| Staff flu vaccination coverage | 42.61% |
42%
0.6 pts better
|
Numerator 49 · Denominator 115 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
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 · Adjusted 2.2 · Observed 1.9 · Expected 1.7 · Used in QM five-star |
| 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 · Adjusted 3.1 · Observed 2.8 · Expected 1.5 · Used in QM five-star |
| 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 · Q1 87.7% · Q2 90.0% · Q3 100.0% · Q4 94.9% · 4Q avg 93.0% |
| 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 · 4Q avg 89.7% |
| 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 · Q1 1.8% · Q2 1.7% · Q3 1.9% · Q4 1.7% · 4Q avg 1.7% · Used in QM five-star |
| 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 · Q1 7.7% · Q2 5.3% · Q3 2.0% · Q4 1.8% · 4Q avg 4.2% |
| 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 · Q1 4.8% · Q2 8.0% · Q3 4.5% · Q4 0.0% · 4Q avg 4.3% |
| 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 · Q1 21.7% · Q2 20.0% · Q3 15.2% · Q4 22.0% · 4Q avg 19.8% |
| 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 · Q1 18.2% · Q2 15.0% · Q3 12.8% · Q4 10.8% · 4Q avg 14.1% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| 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 · Q2 36.1% · Q3 18.9% · Q4 42.7% · 4Q avg 34.5% · Used in QM five-star |
| 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 · Q1 30.2% · Q2 31.0% · Q3 22.7% · Q4 27.1% · 4Q avg 27.7% · Used in QM five-star |
| 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 · Q1 3.0% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 1.2% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 3.9% · Q4 6.9% · 4Q avg 2.7% · Used in QM five-star |
| 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 · Q1 30.9% · Q2 19.8% · Q3 28.8% · Q4 23.3% · 4Q avg 25.5% |
| 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 · Q1 6.8% · Q2 9.6% · Q3 1.7% · Q4 1.5% · 4Q avg 5.0% · Used in QM five-star |
| 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 · Q1 56.7% · Q2 65.2% · Q3 73.5% · Q4 70.0% · 4Q avg 66.9% |
| 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 · 4Q avg 1.9% · Used in QM five-star |
| 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 · 4Q avg 40.9% |
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
Nearby options
Other facilities in reach
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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
#2
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5-star overall rating with 5-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Riverview At The Park Care And Rehabilitation Cent
Sainte Genevieve, MO
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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