Tri-State Village: Fall Safety Failures for MS Resident - IL
The resident, identified in inspection records only as R3, had a care plan in place since August 2024 spelling out the risks in plain terms: she was at risk for falling because of her MS, and the goal was that she remain free from injury. The approaches listed were specific, staff education on proper lift use, verbal reminders not to transfer without assistance, physical therapy consultation, keeping the bed in its lowest position with brakes locked, keeping the call light within reach at all times.
The facility's own portable lift policy, revised in August 2008, states the device must be operated by two staff members. That policy had been on the books for nearly two decades.
The gap between what the care plan required and what inspectors documented was the violation. CMS cited the facility for failing to ensure R3 received the safe transfer assistance her condition demanded.
Federal inspectors classified the harm level as minimal or potential, and noted only a few residents were affected. But for someone whose diagnosis already takes away control over her own body, the failure to follow a two-person lift protocol isn't a paperwork problem. A fall for a person with MS-related spasticity and lower extremity weakness carries real consequences, the kind the care plan itself acknowledged when it set "remain free from injury" as the goal.
The facility's falls protocol required staff to assess vital signs, neurological status, range of motion, and precipitating factors within 24 hours of any fall. Whether R3 fell before inspectors arrived, the report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Tri-state Village Nrsg & Rhb from 2025-08-27 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
TRI-STATE VILLAGE NRSG & RHB in LANSING, IL was cited for violations during a health inspection on August 27, 2025.
The facility's own portable lift policy, revised in August 2008, states the device must be operated by two staff members.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.