Tri-State Village: Wrong Lift Used in Resident Fall - IL
Her care plan said to use a sit-to-stand machine.
The resident, identified in inspection records only as R3, has multiple sclerosis. She has lower extremity weakness, numbness, and spasticity. The facility had documented all of this. A care plan dated November 18, 2024, spelled out the transfer equipment to use: the sit-to-stand lift. The goal written into that plan was that she would be "safely transferred utilizing Sit-to-stand lift through next review."
The CNA used a Hoyer lift instead.
A Hoyer lift is a full-body sling device, different in design and operation from a sit-to-stand machine. The facility's own portable lifting policy, revised in August 2008, requires that the portable lift be operated by two staff members. The inspection record does not document whether a second staff member was present when R3 slipped and fell.
After the fall, a nurse performed a full body assessment. No redness, no deformation, no bruising. R3 said she was not in pain. The attending nurse practitioner was notified. Staff tried to reach family members and couldn't — there was no contact information on file.
The incident report carried no precise date.
The care plan for R3 ran to more than a dozen individual approaches for keeping her safe during transfers: lock the wheelchair brakes, ensure proper footwear, maintain body alignment, observe for pain, follow physical and occupational therapy recommendations on transfer type and weight-bearing status. A separate fall-risk care plan, dated August 30, 2024, listed staff education on proper lift use as a specific intervention and directed staff to obtain a physical therapy consult for transfer training.
None of it prevented a staff member from reaching for the wrong machine.
The facility's falls protocol, listed in an undated policy document, requires that after a fall, staff attempt to identify possible causes within 24 hours. The protocol lists what a nurse must assess and document: vital signs, recent injury, musculoskeletal function, neurological status, precipitating factors, details on how the fall occurred, all current medications, all active diagnoses.
The inspection record does not reflect whether that cause identification was completed within 24 hours, or whether the precipitating factor — the wrong lift — was formally documented as the cause at all.
Federal inspectors cited the deficiency under the accident hazards and supervision standard, rating the level of harm as minimal harm or potential for actual harm.
R3 walked inspectors through it herself, in her own words, with no imprecision about what had gone wrong. The CNA was trying to get her from her wheelchair to bed. The Hoyer lift. She slipped. She fell on her buttocks.
Her care plan had named the right equipment for months. It was there in writing, dated, signed, filed. The staff member who transferred her either didn't check it or didn't follow it. The inspection record does not say which.
What it does say is that a woman with a disease that has already taken her ability to transfer herself independently ended up on the floor, in a facility that had documented exactly how to prevent that from happening.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 1, 2026 · Our methodology
TRI-STATE VILLAGE NRSG & RHB in LANSING, IL was cited for violations during a health inspection on August 27, 2025.
Her care plan said to use a sit-to-stand machine.
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.