Tripoli Nursing & Rehab

Inspectors wroteBased on observation, clinical record review and staff interview the facility failed to implement a soft palm grip cushion to the right hand or bilateral hand splints per Occupational Therapy (OT) recommendation to minimize the risk of contracture for 1 of 1 resident's sampled (Resident #21). The facility identified a census of 24 residents.

Inspectors wroteBased on facility record review, facility policy, personnel files, observation and staff interviews, the facility failed to handle and process soiled laundry to prevent cross transmission or the spread of infection in 1 laundry room observed. The facility reported a census of 24 residents. Findings Include:Observation on 7/23/25 at 10:49 AM revealed a 33-gallon covered empty bin with a label stating soiled linens go here. A pile of soiled soaker pads and bed linens were observed directly on the floor in front of a standard washing machine. Staff A, Laundry Services entered the laundry area from the clean side entrance and stood on top of the soiled linens and soaker pads. Staff A, stepped off the linens and explained soiled laundry comes into the laundry room in bags. [...]

Inspectors wroteBased on Resident rights policy/procedure review, resident and staff interview the facility failed to treat a resident with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 2 out of 4 resident reviewed. (Resident #1 and Resident #3). The facility identified a census of 26 residents.

Inspectors wroteBased on staff and resident interviews, facility investigation, and review of policy and procedures, the facility failed to ensure all alleged violations involving mistreatment, neglect, or abuse of a resident and/or residents (Resident #1) were reported to the Department of Inspection and Appeals and Licensing (DIAL) within 2 hours. The facility reported a census of 26 residents.

Inspectors wroteBased on observation, resident and staff interview the facility failed to properly secure a resident in a wheelchair in the facility van which resulted in the resident tilting backwards in the van while going up a steep hill (Resident #2). The facility census was 26 residents.

Inspectors wroteBased on clinical record review, policy/procedure review, and staff interview the facility failed to treat residents with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 2 out of 6 residents reviewed (Resident #5 and Resident #6). The facility identified a census of 24 residents.

Inspectors wroteBased on clinical record review, resident and staff interview the facility failed to complete a two person transfer by giving the resident a one person bear hug transfer for 1 of 3 residents reviewed (Resident #9). The facility census was 24 residents.

Inspectors wroteBased on observation, staff interview, and process review, the facility failed to ensure 4 of 4 residents received a well-balanced diet that met their nutritional needs. The facility reported a census of 24 residents.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to serve food maintained at a safe and appetizing temperature. The facility reported a census of 24 residents.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to serve the appropriate diet for 1 of 5 residents with an order for mechanical soft/ground diet (Resident #23). The facility reported a census of 24 residents.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to store food in accordance with professional standards for food service safety. The facility reported a census of 24 residents.

Inspectors wroteBased on facility record review and staff interviews, the facility failed to provide satisfactory evidence that they identified their own high risk, high volume, and problem-prone quality deficiencies, and made a good faith attempt to correct them. The facility reported a census of 24 residents.

Inspectors wroteBased on record review, staff interview, and Resident Assessment Instrument (RAI) Manual review the facility failed to ensure 1 of 2 residents (Resident #20) Significant Change Minimum Data Set (MDS) assessments were completed within 14 days of identifying a significant change occurred. The facility reported a census of 24 residents.

Inspectors wroteBased on facility record review, staff interview, and policy review, the facility failed to maintain a valid Pre-admission Screening and Resident Review (PASRR) for 1 of 1 residents screened (Resident #14). The facility reported a census of 24 residents. Findings Include: The Minimum Data Sample (MDS) for Resident #14, dated 06/28/24, indicated a brief interview for mental status (BIMS) score of 12, indicating moderate cognitive impairment. Diagnoses of Stroke, Seizure Disorder, Depression, and Mild Intellectual Disabilities. Review of a PASRR for Resident #14, dated 12/27/23, determined a Level II short term approval ending on 1/26/24. Indicating nursing facility care for now but should return to a setting in the community. Review of Resident #14's Care Plan, dated 12/29/24, failed to document determined PASRR Level II and services to be provided. [...]

Inspectors wroteBased on facility record review, staff interview, and policy review, the facility failed to develop a resident's comprehensive Care Plan and ensure Pre-admission Screening and Resident Review Level II service recommendations were added to the resident's comprehensive Care Plan for 1 of 3 residents reviewed (Resident #14). The facility reported a census of 24 residents. Findings Include: The Minimum Data Sample (MDS) for Resident #14, dated 06/28/24, indicated a brief interview for mental status (BIMS) score of 12, indicating moderate cognitive impairment. Diagnoses of Stroke, Seizure Disorder, Depression, and Mild Intellectual Disabilities. Review of Resident #14's Care Plan, dated 12/29/24, failed to document determined PASRR Level II and services. 8/13/24 at 3:14 PM, via email, Staff A, Administrator, stated the facility does not have a Care Plan policy.

Inspectors wroteBased on record review, staff interview, and Resident Assessment Instrument (RAI) Manual review, the facility failed to ensure 3 of 3 residents (Resident #21, #77, and #78) Discharge Minimum Data Set (MDS) assessments were completed when the resident was discharged from the facility. The facility reported a census of 24 residents.

Inspectors wroteBased on staff interview, the facility failed to employ a qualified director of food and nutrition services. The facility reported a census of 25 residents.

Inspectors wroteBased on staff interviews and policy reviews, the facility failed to implement a policy or procedure to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water system; failed to annually review and update the infection control policies. The facility reported a census of 25 residents.

Inspectors wroteBased on clinical record review, document review, policy review, observation, resident and staff interview the facility failed to separate and provide timely intervention to assure safety after a resident to resident altercation for 2 of 2 residents sampled (Resident #4 and #23). The facility identified a census of 25 residents.

Inspectors wroteBased on clinical record review, document review, policy review, resident and staff interviews, the facility failed to ensure that all alleged violations involving abuse and mistreatment are reported immediately, but not later than 24 hours after the allegation is made for a resident to resident altercation without serious bodily injury for 2 of 2 residents sampled (Resident #4 and #23).

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to take actions and thoroughly investigate alleged resident to resident physical contact for 2 of 2 residents reviewed (Resident #4 and #23). The facility reported a census of 25 residents.

Inspectors wroteBased on clinical record review, document review, resident and staff interviews, the facility failed to revise Care Plan interventions as needed for 4 of 12 resident sampled (Resident #4, #8, #23, #24). The Facility identified a census of 25 residents.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to complete an assessment following incidents for 2 of 3 residents reviewed (Resident #4 and Resident #24). The facility reported a census of 25 residents.

Inspectors wroteBased on clinical record review, document review, and staff interview, the facility failed to notify the Long-Term Care Ombudsman Office of a resident transfer for 1 of 1 resident sampled for hospitalization (Resident #21). The facility identified a census of 25 residents.

Inspectors wroteBased on clinical record view and staff interview, the facility failed to transmit 3 of 3 Minimum Data Set (MDS) assessments for the facility within the required timeframe (Resident #2, #5 and #14). The facility reported a census of 25 residents.