Tri-State Village NRSG & RHB

In the surveyor’s words

From the most serious findings on record at Tri-State Village NRSG & RHB, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 23, 2025

  Based on interview and record review, the facility failed to provide adequate supervision to a cognitively impaired resident and provide adequate monitoring of exit doors. This failure affected one of three residents (R1) reviewed for elopement in a sample of three. This failure resulted to an Immediate Jeopardy. The Immediate Jeopardy began on 04/14/2025 at 2:30PM when R1 exited through the locked dining room door without the door alarm going off, went to the patio/courtyard, exited the patio/courtyard gate, and did not come back. V2 (Director of Nursing) and V3 (Assistant Administrator) were notified of the Immediate Jeopardy on 04/18/2025 at 2:18PM. The facility presented an acceptable removal plan, and the immediacy was removed on 04/23/2025. […]

• Immediate jeopardy, isolatedF689Jan 13, 2022

  Based on interview and record review, the facility failed to provide adequate monitoring and assistance for a resident during mealtime to prevent any choking incidents. This applies to 1 of 3 residents reviewed for monitoring during meals in a total sample of 3. This failure resulted in R1 having a choking episode that caused a [CONDITION(S)]. R1 expired because of the [CONDITION(S)]. This was identified as an immediate jeopardy situation that began on [DATE] and was removed on [DATE]. V1 (Administrator) was informed of the immediate jeopardy on [DATE] at 11:00AM. However, the deficiency remains at a level 2 harm until the facility can evaluate the effectiveness of the implementation of their removal plan. Findings Include: 1. […]

• Immediate jeopardy, isolatedF689Oct 26, 2021

  Based on interview and record review, the facility failed to notify the physician of a resident's mental change of condition and failed to have effective interventions in place to monitor a resident with a history of suicidal ideation for 1 of 3 residents (R1) reviewed accidents and incidents in a total sample 10. This failure resulted in R1 being found deceased , with a cord around the neck, and hanging from a doorstop. This was identified as an immediate jeopardy situation that began on [DATE] and was removed on [DATE]. V1 (Administrator) was informed of the immediate jeopardy on [DATE] at 12:30pm. While the immediacy was removed on [DATE], the facility remained out of compliance at a Security Level 2. […]

• Actual harm, isolatedF686Jul 29, 2026

  Based on interview and record review, the facility failed to develop and implement interventions to prevent the development of pressure ulcers for one resident.This failure resulted in R45 developing facility-acquired pressure ulcer to the sacrum area and deep tissue injuries (DTI) to the right heel, that V34 (Wound Care Specialist APRN) identified as preventable wounds.This applies to 1 of 5 residents (R45) reviewed for pressure ulcers in the sample of 19. The findings include: On July 27, 2026, at 9:39 A.M., R45 was observed in bed. She stated that the mattress was too hard to sleep on and that she had developed wounds on her buttocks and left heel. […]

• Actual harm, isolatedF686Mar 13, 2026

  Based on observation, interview and record review the facility failed to assess, monitor and treat residents with multiple pressure ulcers for 2 of 3 residents (R3 and R4) This deficient practice resulted in R3 being hospitalized for necrotizing fasciitis of the wound bed. Findings include: On 3/10/2026 at 2:00pm V14(Certified Nursing Assistant-CNA) said on 10/5/2025 she entered R3 room and V10 said to clean her up she's going out to the hospital the areas on her buttocks were some what dark she did answer me correctly when I told her what I was doing she responded ok. R3 could not turn or reposition herself she was dependent on staff for all care. […]