Tri-State Village: Missed Wound Care Causes Harm - IL
Federal inspectors cited the facility for actual harm following a complaint inspection completed November 17, 2025.
The resident's treatment administration record, which tracks whether ordered wound care was actually delivered each day, covered the period from September 30 through November 17. Inspectors reviewed it and found no documentation that wound care was provided on October 3, October 7, October 8, October 22, October 23, October 24, October 25, October 28, November 4, November 7, November 13, or November 15. Thirteen dates. No entries. No care recorded.
The wound measurements told the story of what that neglect cost.
On October 2, the wound measured 2.9 centimeters long, 0.6 centimeters wide, and just 0.1 centimeters deep. The tissue was 100 percent granulation, the pink, healthy tissue that forms as a wound heals. Six days later, on October 7, a measurement showed the wound unchanged in size, still entirely granulation tissue. It was holding.
Then the gaps in care began to accumulate.
By October 28, the wound had grown. It now measured 3.5 centimeters by 1 centimeter. Still granulation tissue, still technically healing, but larger than it had been three weeks earlier. A wound that should have been closing was spreading.
The November 4 measurement was worse. The wound had reached 3.5 centimeters by 4 centimeters by 0.2 centimeters deep. More than six times the surface area of the wound documented on October 2. And the tissue composition had shifted: 50 percent granulation, 50 percent slough. Half the wound bed was now covered in dead, yellow tissue that does not heal and does not support new growth. It has to be removed before a wound can close.
After November 4, wound management documentation stopped entirely.
Ten days passed with no recorded wound assessment. On November 14, a new wound care physician examined the resident. The wound measured 3 centimeters by 4.3 centimeters by 0.4 centimeters, still split evenly between slough and granulation tissue. The depth had doubled since the October 2 baseline. The slough remained.
The inspection report does not explain why wound care was not documented on those 13 dates. It does not say whether staff attempted treatment and failed to chart it, or whether the resident simply went without. The treatment administration record, the document that exists precisely to answer that question, was blank.
What the record does show is a wound that entered the facility small and healing, survived weeks of inconsistent care, and arrived at mid-November larger, deeper, and burdened with dead tissue that was not present at the start.
Sacral wounds, located at the base of the spine, develop in residents who spend extended time in bed or in a chair. They are among the most preventable and most serious complications in long-term care. A wound at the sacrum sits in a location that is difficult to keep clean and dry, and without consistent treatment, even a small wound can deteriorate quickly. The transition from granulation tissue to slough is not a cosmetic change. It means the wound is no longer progressing toward closure.
The citation carries a level of harm designated as actual harm, the federal finding that a deficiency caused real injury to a resident, not merely the risk of it.
The inspection was triggered by a complaint. The report does not identify who filed it.
Tri-State Village is a nursing and rehabilitation facility in Lansing, a south suburb of Chicago. The November 17 inspection covered only this violation. The report contains no findings about staffing, other residents, or facility-wide practices.
What it contains is a seven-week record of a wound that needed consistent attention and did not receive it, and a resident who came in healing and left the documented period with a wound that had grown, deepened, and begun to die from the inside.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Tri-state Village Nrsg & Rhb from 2025-11-17 including all violations, facility responses, and corrective action plans.
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 1, 2026 · Our methodology
TRI-STATE VILLAGE NRSG & RHB in LANSING, IL was cited for violations during a health inspection on November 17, 2025.
Federal inspectors cited the facility for actual harm following a complaint inspection completed November 17, 2025.
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.