01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-04-30 | 19 | 2025-04-30 | 12 |
| Cycle 2 | 2024-04-26 | 11 | 2024-04-26 | 11 |
| Cycle 3 | 2023-01-19 | 24 | 2023-01-19 | 13 |
CMS CCN 1458792026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Tri-State Village Nrsg & Rhb
2500 East 175Th Street · Lansing, IL 60438 · Cook County
Certified beds84CMS provider file
Recent citation rows90current CMS citation release
Penalty rows8current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
90 rows in the current release
11 rows carry G–L scope/severity codes; 1 carry J–L. 18 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-03-13 · HEALTHF0686Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2026-03-27 · complaint2026-03-13 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2026-03-27 · complaint2025-11-17 · HEALTHF0686Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2025-12-05 · complaint2025-08-27 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-09-05 · complaint2025-08-27 · HEALTHF0940Severity F · widespread; potential for more than minimal harm
Administration Deficiencies
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Correction field: Deficient, Provider has date of correction · 2025-09-05 · complaint2025-04-30 · FIREE0004Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Develop and maintain an Emergency Preparedness Program (EP).
Correction field: Deficient, Provider has date of correction · 2025-05-232025-04-30 · FIREE0006Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct risk assessment and an All-Hazards approach.
Correction field: Deficient, Provider has date of correction · 2025-05-232025-04-30 · FIREE0007Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Address patient/client population and determine types of services needed.
Correction field: Deficient, Provider has date of correction · 2025-05-232025-04-30 · FIREE0013Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Develop Emergency Preparedness policies and procedures.
Correction field: Deficient, Provider has date of correction · 2025-05-232025-04-30 · FIREE0026Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish roles under a Waiver declared by secretary.
Correction field: Deficient, Provider has date of correction · 2025-05-232025-04-30 · HEALTHF0644Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Correction field: Deficient, Provider has date of correction · 2025-05-232025-04-30 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2025-05-232025-04-30 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-05-232025-04-30 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2025-05-232025-04-30 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-05-232025-04-30 · HEALTHF0692Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Correction field: Deficient, Provider has date of correction · 2025-05-232025-04-30 · HEALTHF0725Severity C · widespread; potential for minimal harm
Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Correction field: Deficient, Provider has date of correction · 2025-05-232025-04-30 · HEALTHF0740Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Correction field: Deficient, Provider has date of correction · 2025-05-232025-04-30 · HEALTHF0755Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2025-05-232025-04-30 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Correction field: Deficient, Provider has date of correction · 2025-05-232025-04-30 · HEALTHF0851Severity C · widespread; potential for minimal harm
Administration Deficiencies
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Correction field: Deficient, Provider has date of correction · 2025-05-232025-04-30 · HEALTHF0881Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Correction field: Deficient, Provider has date of correction · 2025-05-232025-04-30 · HEALTHF0921Severity E · pattern; potential for more than minimal harm
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Correction field: Deficient, Provider has date of correction · 2025-05-23 · complaint2025-04-30 · HEALTHF0947Severity E · pattern; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Correction field: Deficient, Provider has date of correction · 2025-05-2303 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2026-03-13 | Fine | $50,915 | 0 |
| 2025-11-17 | Fine | $46,900 | 0 |
| 2025-04-23 | Payment Denial | $0 | 16 |
| 2024-06-28 | Fine | $23,651 | 0 |
| 2024-06-28 | Payment Denial | $0 | 30 |
| 2024-02-09 | Fine | $52,858 | 0 |
| 2023-09-05 | Fine | $105,486 | 0 |
| 2023-09-05 | Payment Denial | $0 | 51 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- GEMINO HEALTHCARE FINANCE LLCOrganization · 5% OR GREATER SECURITY INTERESTNOT APPLICABLE · since 03/31/2023
- ASADULLAH, KHAJAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/01/2018
- MASHIACH, YAACOVIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/01/2018
- MASHIACH, YECHIELIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/01/2018
- MASHIACH, YEHOSHUAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/01/2018
- ASADULLAH, KHAJAIndividual · ADP OF THE SNFNOT APPLICABLE · since 12/01/2018
- MASHIACH, YEHOSHUAIndividual · ADP OF THE SNFNOT APPLICABLE · since 12/01/2018
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.29per resident day
RN hours0.78per resident day
Weekend nurse hours2.82per resident day
Staff turnover25.8%CMS reported field
06 / LOCAL RECORDS
Open the Illinois ledger →Other published facilities nearby
No second facility in the same city met the directory rule.