Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
TRI-STATE VILLAGE NRSG & RHB
LANSING, IL · 84 certified beds · Last Life Safety survey April 30, 2025
CMS Certification Number 145879 · first certified May 1996
Ownership
Operated by ATIED ASSOCIATES · For profit - Limited Liability company
- Ownership changed December 1, 2018 (change of ownership)to TRI-STATE VILLAGE NURSING AND REHABILITATION CENTER from TRI-STATE NURSING & REHABILITATION CENTER INC
Position within IL
36 citations — more than 90% of the 666 certified nursing homes in IL. Compared within IL rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 12 citations; the earlier surveys in the window averaged 12. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (March 2026 to June 2026), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was April 2025. Facilities in IL are typically surveyed 11–13 months after the last one (median 12), measured over 759 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
10 of the 36 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
9 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 36 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in IL, and nationally. Surveyors differ markedly between states, so the IL figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 36 |
| Median facility in IL | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| January 19, 2023 | 13 |
| April 26, 2024 | 11 |
| April 30, 2025 | 12 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | 3 | 2025-04-30 |
| K-0363 | Install corridor and hallway doors that block smoke. | 3 | 2025-04-30 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 2 | 2025-04-30 |
| E-0013 | Develop Emergency Preparedness policies and procedures. | 2 | 2025-04-30 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2025-04-30 |
| K-0271 | Have exits that are accessible at all times. | 2 | 2024-04-26 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2024-04-26 |
| K-0351 | Install an approved automatic sprinkler system. | 2 | 2025-04-30 |
What the citations cover
- Smoke Deficiencies 11
- Emergency Preparedness Deficiencies 10
- Egress Deficiencies 7
- Gas, Vacuum, and Electrical Systems Deficiencies 6
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 11 |
| Emergency Preparedness Deficiencies | 10 |
| Egress Deficiencies | 7 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 6 |
| Miscellaneous Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
April 30, 2025 — 12 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (May 23, 2025) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (May 23, 2025) |
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (May 23, 2025) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (May 23, 2025) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (May 23, 2025) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (May 30, 2025) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (May 23, 2025) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (May 23, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (May 23, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (May 23, 2025) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (May 23, 2025) |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Deficient, Provider has date of correction (May 23, 2025) |
April 26, 2024 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (May 24, 2024) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (May 24, 2024) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (May 24, 2024) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (May 24, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (May 24, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (May 24, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 24, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (May 24, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (May 24, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (May 24, 2024) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (May 24, 2024) |
January 19, 2023 — 13 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (February 18, 2023) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (February 18, 2023) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (February 18, 2023) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (February 18, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (February 18, 2023) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (February 18, 2023) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (February 18, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (February 18, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (February 18, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (February 18, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (February 18, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (February 18, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (February 18, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.