Tripoli Nursing & Rehab

In the surveyor’s words

From the most serious findings on record at Tripoli Nursing & Rehab, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF800Aug 15, 2024

  Based 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. Findings include: During an observation on 8/14/24 at 11:35 AM -12:00 PM of the puree process for carrots, spaghetti, and bread revealed the following: Staff B, Cook, needed to make four servings of pureed carrots, she started by scooping four, four ounce scoops into the food processor. Then added two scoops of thickener and poured in milk and began to puree the carrots. Staff B added another scoop of thickener to make the proper consistency, then transferred the pureed carrots to a steam table pan and placed it in the oven to heat to proper temperature. […]

• No harm, potential for more than minimal, patternF804Aug 15, 2024

  Based 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. Findings include: On 8/12/24 at 12:16 PM, Dining observation revealed a pan of meatloaf sitting on top of the steam table, not inside the table where the heat is held. Review of food temperatures taken prior to serving indicated the meatloaf temperature of 177 degrees Fahrenheit (F). At 12:21 PM, after Staff C, Cook, served the last plate, meatloaf temperature was requested, revealing 64 degrees F. During Dinner observation on 8/14/24 at 6:25, after serving the last resident, Surveyor requested Staff C, Cook, temp pureed fish sticks in the steam table, revealing a temperature of 116 degrees F. […]

• No harm, potential for more than minimal, patternF805Aug 15, 2024

  Based 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. Findings include: Review of Resident #23 Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 scored a 3 out of 15 on the Brief interview for Mental Status (BIMS) indicating severe cognitive impairment . The resident's diagnoses included seizure disorder, dysphagia, injury of head, limitation of activities due to disability, reduced mobility, and gastrostomy. Review of Resident #23 Care Plan dated 7/5/24 identified the resident required tube feedings (G-tube) related to swallowing problems and history of aspiration. […]

• No harm, potential for more than minimal, patternF812Aug 15, 2024

  Based 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. Findings include: On 08/12/24 at 10:15 AM, Initial observation of the kitchen's food storage and freezers revealed the following items were opened, unsealed (open to air), and/or lacked labeling to identify product and opened date; canister of butter, cottage cheese, condiments, milk, half of an apple pie, open package of hamburger buns, bag of stuffing, and a frozen bags of chicken. […]

• No harm, potential for more than minimal, patternF865Aug 15, 2024

  Based 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. Findings include: During an interview on 8/15/24 at 11:10 AM, the Administrator reported there is not a plan in place to do a follow up when concerns are identified to make sure they are continuing to keep a previous deficiency from happening again. Review of the facility's past survey violations document the facility failed to electronically transmit encoded, accurate, and complete MDS data to the CMS System. […]