Tri-state Village Nrsg & Rhb

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

no precised date. Writer asked the resident how the incident happened , and she stated The CNA was trying to get me from my wheelchair to bed using the Hoyer lifter and i slipped off and fell on my buttocks.

Full body assessment performed, no redness , no deformation, no scar or bruises noted . The resident verbalized no pain nor discomfort at this time. Attending NP notified, family members unable to reach due to no contact info. will continue to monitor and assess.Care plan dated 11/18/2024 documents: Resident is limited in functional status in regards to the ability to transfer self. Resident R3 requires the use of sit to stand machine for transfersGoals: In order to improve quality of life and participate in chosen activities, resident will be safely transferred utilizing Sit-to-stand lift through next review.Approach(es): Use appropriate equipment with any mechanical lift device (e.g. straps, slings).Utilize additional staff with transfers when needed.Observe for presence of pain/discomfort (such as verbalization, moaning, groaning, guarding and/or flinching) during transfers.Maintain body in functional alignment during transfers.Ensure safe placement of extremities during transfers.Ensure wheelchair is locked and secured prior to transfer.Provide appropriate foot wear prior to transferKeep call light in reach.Refer to restorative nursing as needed.Praise resident for efforts.Remind resident to not transfer without assistance.Instruct in use of assistive device sit to stand lift as needed.Ensure proper transfer technique.Follow PT/OT recommendations r/t transfer type and weight bearing status.Refer to PT/ OT with any change in transfer status. Care plan dated 8/30/2024 documents: Resident R3 is at risk for falling R/T lower extremity weakness, numbness, and spasticity from multiple sclerosis.Goals: Resident R3 will remain free from injury.Approach(es): Staff education for proper use of liftsOrient [NAME] when there has been new furniture placement or other changes in environment.Assure the floor is free of glare, liquids, foreign objects.Provide proper, well-maintained footwear.Leave night light on in room.Keep bed in lowest position with brakes locked.Keep personal items and frequently used items within reach.Keep call light in reach at all times.Provide Resident R3 with an environment free of clutter.Obtain PT consult for strength training, toning, positioning, transfer training, mobility devices.Provide toileting assistance as needed.Give Resident R3 verbal reminders not to transfer without assistance. Using a Portable Lifting Machine Policy (Revised August 2008) documents:Purpose: The purpose of this procedure is to help lift residents using a manual lifting devicePreparation: 1. Review the resident's care plan to assess for any special needs of the resident.General Guidelines: The portable lift should be used by two staff members. Falls Clinical Protocol Policy undated documents:Assessment and Recognition: 2. In addition, the nurse shall assess and document/report the following:a. Vital signsb. Recent injury, especially fracture or head injuryc.

Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.d. Change in condition or level of consciousnesse. Neurological statusf. Paing. Frequency and number of falls since last physician visith. Precipitating factors, details on how fall occurredi. All current medications, especially those associated with dizziness or lethargyj. All active diagnoses5. The staff will evaluate and document falls that occur while the individual is in the facilty; for example, when and where they happen, any observations of

the events, etc.Cause Identification1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Tri-State Village Nrsg & Rhb

2500 East 175th Street Lansing, IL 60438

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0940 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident's needs.Standards:3. Orientation and initial job training and assessment of staff member's ability to perform specific job duties will be provided for all employees by the respective Department Director or designated staff member prior to working independently.4. Department Directors shall monitor the competency of all staff by observation(s) to continually identify retraining needs in order to assist the employee to improve throughout their employment. Theses competencies include: nursing, oral or nutritional care, rehabilitation, environmental, social service, activities or other functional needs.5. Training of facility personnel shall be supervised by the Department Director and/or their qualified designee.Facility Assessment tool dated 1/17/2025 documents:Part 2: Services and Care We Offer Based on our Residents' NeedsResident support/care needs2.1 List the types of care that your resident population requires and that you provide for your resident population. List by general categories, adding specifics as needed. It is not expected that you quantify each care or practice in terms of the number of residents that need that care, or enter an aggregate of all resident care plans here. The intent is to identify and reflect on resources needed (in Section 3) to provide these types of care.General Care Specific Care or PracticesActivities of daily living Bathing, showers, oral/denture care, dressing, eating, support with needs related to hearing/vision/sensory impairment; supporting resident independence in doing as much of these activities by himself/herselfMobility and fall/fall with Transfers, ambulation, restoreative nursing, contracture Injury prevention prevention/care; supporting resident independence in doing as much of these activities by himself/herself 3.4 Describe the staff training/education and competencies that are necessary to provid the level and types of support and care needed for your resident population. Include staff certification requirements as applicable. Potential data resources include hiring, education, training, competency instruction, and testing policies. Aside from having licensure/certifications as required by law, the facliity has

a comprehensive orientation program and annual in-service calendar. As needed, the facility continues to re-educate staff on specific areas of improvement. Included: Orientation checklist, In-service Calendar, Nurse & CNA Competency.Physical environment and building/plant needs3.8 List physical resources for the following categories. Review the resources in the example below and modify as needed. If applicable, describe your processes to ensure adequate supplies and to ensure equipment is maintained to protect and promote the health and safety of residents. Physical equipment Bath benches, shower chairs, bathroom Maintenance Director to keep in safety bars, bathing tubs, sinks for good working conditions.

Residents and for staff, scales, bed scales Accurate Scale for all lifts and Ventilators, wheelchairs and associated scales. Positioning devices, bariatric beds, Contracted companies for Bariatric wheelchairs, lifts, lift slings, bed all DME's (durable medical Frames, mattresses, room and common equipment that are needed. Space furniture, exercise equipment, Therapy tables/equipment, walkers, Canes, nightlights, steam table, oxygen Tanks and tubing, dialysis chair and Station, ventilators

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