Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tripoli Nursing & Rehab during CMS and state inspections, most recent first.
A resident did not receive the necessary care and services to maintain or improve ROM, limited ROM, or mobility, and there was no documented medical reason for the decline.
A staff member responsible for laundry services routinely placed soiled linens and soaker pads directly on the floor, stood on them, and did not consistently use personal protective equipment such as gowns when handling soiled laundry. The staff member also failed to clean or cover shoes before delivering clean linens, and the facility's policies lacked clear guidance on proper containment and PPE use. Previous warnings for substandard work and missing job description documentation were also noted.
Two residents experienced disrespectful and undignified treatment by staff, including rough handling during transfers, unprofessional conversations overheard in hallways, and uncompassionate or demanding communication. One resident reported being pushed into bed by a CNA who was visibly upset, while another described staff speaking inappropriately and delaying care. These actions were confirmed through resident interviews and internal investigation, violating the facility's policy on resident rights.
A resident with moderate memory impairment and multiple health conditions reported being handled roughly by a CNA during a transfer to bed, an incident witnessed by another resident who also described the staff member as rude and inattentive. The facility's internal investigation confirmed the transfer may have been performed in a rough manner, but the required report to authorities was not made within the mandated 2-hour window, in violation of policy.
A resident with multiple chronic conditions was transported in a facility van without being properly secured in their wheelchair, as only three out of four required q-straints were used and the staff member had not received training on the van's restraint system. The wheelchair tipped backwards while going up a steep hill, prompting the staff to pull over and readjust the restraints. The facility lacked policies, procedures, and documentation related to safe transport and staff competency in this area.
Two residents with cognitive impairments experienced deficiencies in care related to dignity and respect. A resident with dementia and another with a traumatic brain injury were involved in incidents where a CNA made inappropriate comments. Despite care plans emphasizing communication and engagement, staff failed to uphold these standards, leading to deficiencies in maintaining a respectful environment.
A resident with seizure disorder and musculoskeletal impairment, requiring two-person assistance for transfers, was improperly transferred by a single CNA using a bear hug technique. Despite having a gait belt, it was not utilized during the transfer, contrary to the care plan. The facility administrator confirmed this was not the proper method.
The facility failed to store food safely, with several items found unsealed and unlabeled in the kitchen's storage and freezers. A slimy wet area was also observed in the walk-in cooler. The Administrator acknowledged these issues and confirmed the absence of a policy on food storage and labeling.
The facility failed to identify and address high-risk, high-volume, and problem-prone quality deficiencies. The Administrator admitted there was no follow-up plan for identified concerns, leading to repeated violations, including failure to transmit accurate MDS data to CMS. Despite having a QAPI Plan from 2014, the facility did not adhere to it, lacking a process to prevent recurrence of deficiencies.
The facility failed to ensure residents received a well-balanced diet due to inaccuracies in the puree process and portion sizes. Staff B, the cook, did not follow the correct procedure for measuring pureed food, resulting in incorrect portions being served. The facility administrator acknowledged the issue and noted the absence of a policy for therapeutic diets or food preparation.
The facility failed to maintain food at safe temperatures during dining service. A pan of meatloaf was left on top of the steam table, dropping from 177°F to 64°F by the last serving. Pureed fish sticks were also found at 116°F, below the required 135°F. Staff confirmed the need to hold hot foods at 135°F or above, as per facility policy.
A resident with severe cognitive impairment and swallowing issues was served an inappropriate meal that did not meet the prescribed mechanical soft diet. Despite a second check system, dietary staff failed to ensure the meal complied with the resident's dietary needs, and the facility lacked a policy for therapeutic diets.
A facility failed to complete a Significant Change MDS for a resident who was placed on hospice care, as required by the RAI Manual. Despite staff acknowledging the need for such assessments, the facility lacked a specific policy for MDS completion, leading to the oversight.
A facility failed to maintain a valid PASRR for a resident with moderate cognitive impairment and multiple diagnoses. The resident's care plan did not document the required PASRR Level II or services. The ADON admitted to not resubmitting the PASRR due to a lack of understanding of the process, and the facility lacked a PASRR policy.
A facility failed to develop a comprehensive care plan for a resident with moderate cognitive impairment and multiple diagnoses, omitting necessary PASRR Level II service recommendations. The care plan did not document these services, and the facility lacked a care plan policy.
The facility failed to complete Discharge MDS assessments for three residents upon their discharge, as required by the RAI Manual. A resident was discharged to home, another to a different facility, and a third to home, all lacking documentation of completed discharge MDS assessments. Interviews with the ADON and DON confirmed adherence to the RAI manual, which requires a Discharge MDS within 14 days post-discharge, but the facility lacked a specific MDS completion policy.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to ensure that appropriate care and services were provided to prevent a decline in these areas, except when such a decline was medically unavoidable. The report notes that the necessary interventions to support or enhance the resident's ROM or mobility were not implemented as required.
Failure to Prevent Cross-Contamination in Laundry Handling
Penalty
Summary
The facility failed to properly handle and process soiled laundry in a manner that would prevent cross transmission or the spread of infection. During observation, soiled soaker pads and bed linens were found directly on the floor in front of a washing machine, rather than being contained in the designated bin. A staff member responsible for laundry services was observed entering the laundry area from the clean side, standing directly on the soiled linens and soaker pads, and admitting that this was her usual practice. She also reported not wearing a gown when sorting soiled laundry and did not clean or cover her shoes before delivering clean linens to resident rooms. The staff member stated that she mops the laundry room floor at the end of each day and cleans the bottom of her shoes by stepping on the mop, and she is the only person working in laundry each day. Review of the staff member's personnel file revealed a lack of a signed job description for the Laundry Services position and previous documented warnings for substandard work, including not mopping the laundry room and improper handling of soiled resident clothing. The facility's Laundry Protocol policy stated that soiled linens should be handled safely to avoid contamination but lacked specific guidance on the use of gowns, gloves, and containment of soiled laundry. The Standard Precautions policy outlined the use of personal protective equipment and safe handling of potentially infectious materials but did not appear to be consistently followed in practice, as evidenced by the staff member's actions and statements.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to treat two residents with respect and dignity, as required by resident rights policies. One resident, who had moderate memory impairment and required assistance with mobility and personal hygiene, reported that a CNA grabbed their upper arms and pushed them into bed during an evening shift. The resident did not report any injury but described the staff member as being rough and acting out of anger towards another staff member. The incident was not initially reported by the resident and the exact date was not recalled, but the resident confirmed the rough handling during an internal interview. Another resident, who had no memory impairment but required substantial assistance with activities of daily living, reported overhearing staff discussing inappropriate topics in the hallways and speaking to residents in a demanding and uncompassionate manner. This resident also experienced delays in care, being told to wait for repositioning because staff were conducting rounds. The resident identified specific staff members as being less compassionate and less effective when working together, and expressed that the manner in which they were spoken to was not ethical. The facility's internal investigation confirmed that concerns about staff roughness and inappropriate conversations were discussed during a resident council meeting. Interviews with the affected residents corroborated the reports of rough handling, lack of compassion, and unprofessional staff interactions. The facility's policy states that all residents are to be treated with respect and dignity, and the administrator verified this expectation during the investigation.
Failure to Timely Report Alleged Staff Roughness to Authorities
Penalty
Summary
The facility failed to report an alleged incident of staff-to-resident roughness to the Department of Inspection and Appeals and Licensing (DIAL) within the required 2-hour timeframe. The incident involved a resident with moderate memory impairment and multiple medical conditions, including heart failure, hypertension, diabetes, and anxiety. The resident required substantial assistance with activities of daily living, such as toileting and transfers. During an evening shift, a CNA was reported to have grabbed the resident's upper arms and pushed them into bed. The resident did not initially report the incident and could not recall the exact date, but later described the staff member as being rough, possibly due to anger directed at another staff member. The facility's internal investigation was prompted by concerns raised during a resident council meeting about staff roughness and inappropriate conversations. Interviews with the resident and another witness revealed that the CNA's behavior was perceived as rough and unprofessional, with additional complaints about the staff member's attitude and failure to provide adequate care, such as not changing the resident's clothes or properly assisting with toileting. The Director of Nursing conducted a reenactment and determined that, while the transfer was technically correct, it may have been performed in a manner considered rough or too quick by the resident. Despite these findings and the facility's policy requiring immediate reporting of all abuse allegations to DIAL within 2 hours, the facility did not notify the authorities within the mandated timeframe. The administrator confirmed this failure to report the incident promptly, which constituted a violation of both facility policy and regulatory requirements.
Failure to Properly Secure Resident in Wheelchair During Van Transport
Penalty
Summary
A deficiency occurred when a resident was not properly secured in a wheelchair during transport in the facility van, resulting in the wheelchair tilting backwards while ascending a steep hill. The resident, who had diagnoses including heart failure, hypertension, diabetes mellitus, depression, and chronic pain, was cognitively intact and required supervision or assistance with activities of daily living and mobility. During the incident, only three q-straints were used to secure the wheelchair, although the van was typically equipped with four. The staff member responsible for transport did not receive training or have access to a checklist or user manual for securing wheelchairs in the van, and was unaware of the missing fourth q-straint prior to the trip. The staff member transporting the resident noticed the wheelchair tipping back after the resident called out, prompting the staff to pull over and readjust the restraints. It was observed that the front wheels of the wheelchair were off the floor and the back was not properly secured, which contributed to the instability. The staff member later reported the incident to the DON and provided a written statement, but there was no documentation in the resident's chart, no incident report, and no follow-up recorded regarding the event. Further investigation revealed that the facility lacked policies, procedures, or guidelines for securing residents in the van with q-straints, and there was no evidence of staff education or competency checks related to this process. The administrator was unaware of the incident until informed by surveyors and confirmed the absence of relevant documentation, training materials, or a user manual for the van's restraint system.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to treat two residents with respect and dignity, which compromised their quality of life. Resident #5, who has diagnoses including heart failure, hypertension, and dementia, was found to have severely impaired decision-making abilities and was dependent on staff for daily living activities. The resident's care plan included interventions to converse with the resident during care and to manage agitation. However, staff reported decreasing communication and blank stares from the resident, indicating a lack of engagement. Additionally, there was an incident involving a sexual comment made by Staff A, a CNA, which was not reported to the charge nurse as the staff felt they had managed the situation. Resident #6, with diagnoses including anemia, hypertension, and a history of traumatic brain injury, also experienced a deficiency in care. The resident had moderately impaired decision-making abilities and required assistance with daily living activities. The care plan emphasized the need for staff to converse with the resident and redirect inappropriate language. Despite this, another improper conversation involving Staff A was reported, indicating a failure to maintain appropriate communication standards. Both residents were assessed for safety and reported feeling safe, with no signs of physical abuse or changes in behavior. However, the incidents involving Staff A's conversations highlight a failure to uphold the residents' rights to dignity and respect. Staff interviews revealed a need for re-education on abuse policies and proper communication, underscoring the facility's deficiency in ensuring a respectful environment for its residents.
Improper Transfer Technique Used for Resident
Penalty
Summary
The facility failed to adhere to the care plan for a resident requiring assistance with transfers. Resident #9, who has a history of seizure disorder, epilepsy, and musculoskeletal impairment, was documented in the Minimum Data Set (MDS) as needing substantial/maximal assistance with transfers and the use of a wheelchair for mobility. The resident's Plan of Care specified that two staff members were required to assist with stand/pivot transfers every two hours and as necessary. However, it was found that the resident was transferred by a single staff member using a bear hug technique, contrary to the care plan's instructions. Interviews conducted with Resident #9 and Staff B, a Certified Nursing Assistant (CNA), confirmed that the transfer was performed by one person using a bear hug, and although a gait belt was placed around the resident's waist, it was not utilized during the transfer. The facility administrator also confirmed that the bear hug method was not the proper way to transfer the resident, acknowledging the deviation from the prescribed care plan. This incident highlights a failure in following the established protocols for resident transfers, potentially compromising the resident's safety and well-being.
Failure to Store Food Safely
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, as observed during a survey. During an inspection of the kitchen's food storage and freezers, several items were found to be opened, unsealed, and lacking proper labeling to identify the product and the date it was opened. These items included a canister of butter, cottage cheese, condiments, milk, half of an apple pie, an open package of hamburger buns, a bag of stuffing, and frozen bags of chicken. Additionally, a slimy wet area was observed on the floor of the walk-in cooler. In an interview, the facility's Administrator acknowledged that these items should have been sealed, labeled, dated when opened, and discarded when necessary. The Administrator also acknowledged the presence of the slimy wet area in the walk-in cooler. Furthermore, it was revealed that the facility does not have a policy on food storage and labeling.
Failure to Address Quality Deficiencies
Penalty
Summary
The facility failed to provide satisfactory evidence of identifying and addressing high-risk, high-volume, and problem-prone quality deficiencies. During an interview, the Administrator admitted that there was no plan in place to follow up on identified concerns to ensure that previous deficiencies do not recur. A review of the facility's past survey violations revealed that the facility failed to electronically transmit encoded, accurate, and complete MDS data to the CMS System, and continued to be in violation without an implementation plan to correct the identified quality deficiency. The facility's QAPI Plan, dated 2014, directed a focus on systems and processes, encouraging staff to identify potential errors and system breakdowns, set goals to improve performance, measure progression toward the goal, and revise it as necessary. However, the facility did not demonstrate adherence to this plan, as evidenced by the lack of a follow-up process and continued violations.
Inaccurate Puree Process and Portion Sizes
Penalty
Summary
The facility failed to provide a well-balanced diet that met the nutritional needs of four residents, as observed during the puree process for carrots, spaghetti, and bread. Staff B, the cook, was responsible for preparing pureed meals but did not follow the established puree process correctly. Specifically, Staff B did not measure the pureed food accurately or use the puree scoop chart to determine the correct portion sizes for each resident. This resulted in inaccurate portion sizes being served at lunch. During an interview, Staff B admitted to being unaware of the proper process for measuring pureed food and acknowledged that the portions served were not accurate. Additionally, the facility administrator, Staff A, confirmed that the puree process was not completed correctly and that the facility lacked a policy for therapeutic diets or food preparation. The facility had a census of 24 residents at the time of the survey.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain food at a safe and appetizing temperature, as observed during dining service. On one occasion, a pan of meatloaf was left sitting on top of the steam table rather than inside it, resulting in a temperature drop from 177 degrees Fahrenheit to 64 degrees Fahrenheit by the time the last plate was served. On another occasion, pureed fish sticks were found to be at 116 degrees Fahrenheit in the steam table, below the required 135 degrees Fahrenheit. Staff interviews confirmed that hot foods should be held at 135 degrees Fahrenheit or above, and cold foods at 41 degrees Fahrenheit or below, as per the facility's policy on Cooking and Hot Holding Food. The policy emphasizes maintaining these temperatures to prevent bacterial growth in potentially hazardous foods.
Failure to Serve Appropriate Diet to Resident with Swallowing Issues
Penalty
Summary
The facility failed to provide the appropriate diet for a resident with severe cognitive impairment and a history of swallowing problems. The resident, who had a gastrostomy and required tube feedings, was evaluated by Speech Therapy (ST) and recommended a mechanical soft diet with ground meats and gravy for lubrication, along with thinned liquids under direct supervision. Despite these orders, during a dinner observation, the resident was served mechanical soft fish sticks and potato wedges that did not meet the prescribed diet requirements. The potato wedges were served with skin, and the fish sticks lacked the necessary gravy. The facility had implemented a second check of plated food by the floor nurse prior to serving, following a previous incident of aspiration by another resident. However, during the dinner service, dietary staff failed to have the nurse or staff perform this second check. The facility administrator, who was present at the time, confirmed that the food served did not comply with the mechanical soft diet orders. Additionally, the facility lacked a policy for therapeutic diets or food preparation, as verified by the administrator.
Failure to Complete Significant Change MDS for Hospice Enrollment
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for one resident within the required 14-day period after a significant change in condition was identified. Specifically, the resident was placed on hospice care on December 29, 2023, but the necessary MDS assessment was not conducted by August 12, 2024. This oversight was identified through a review of the resident's records, which showed no completion of the Significant Change MDS following the resident's enrollment in hospice care. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), confirmed that the facility follows the Resident Assessment Instrument (RAI) Manual, which mandates the completion of a Significant Change MDS when a resident enrolls in hospice. However, the facility lacked a specific policy for MDS completion, relying solely on the RAI Manual. The RAI Manual, as of October 2023, clearly states that a Significant Change MDS must be performed within 14 days of a resident's hospice election to ensure a coordinated care plan between the hospice and the nursing home.
Failure to Maintain Valid PASRR for Resident
Penalty
Summary
The facility failed to maintain a valid Pre-admission Screening and Resident Review (PASRR) for a resident with moderate cognitive impairment and multiple diagnoses, including stroke, seizure disorder, depression, and mild intellectual disabilities. The resident's Minimum Data Sample (MDS) indicated a Brief Interview for Mental Status (BIMS) score of 12. A PASRR dated December 27, 2023, determined a Level II short-term approval ending on January 26, 2024, suggesting that the resident should return to a community setting. However, the resident's care plan, dated December 29, 2024, did not document the determined PASRR Level II or the services to be provided. During an interview, the Assistant Director of Nursing (ADON) acknowledged that the PASRR had not been resubmitted due to a lack of understanding of the process and the short-term PASRR requirements. The resident, initially intended to return to the community, had not been transitioned due to current health concerns and had accepted long-term care in the facility. The ADON also admitted to the failure to update the resident's care plan to include PASRR services. The facility administrator confirmed via email that there was no PASRR policy in place, and the facility followed regulatory guidelines.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, specifically neglecting to include Pre-Admission Screening and Resident Review (PASRR) Level II service recommendations. This deficiency was identified for one of the three residents reviewed, who had a census of 24 residents. The resident in question had a Minimum Data Set (MDS) indicating moderate cognitive impairment, with diagnoses including stroke, seizure disorder, depression, and mild intellectual disabilities. Despite these conditions, the care plan dated December 29, 2024, did not document the necessary PASRR Level II services. Additionally, the facility administrator confirmed via email that the facility lacked a care plan policy.
Failure to Complete Discharge MDS Assessments
Penalty
Summary
The facility failed to complete Discharge Minimum Data Set (MDS) assessments for three residents upon their discharge, as required by the Resident Assessment Instrument (RAI) Manual. Resident #21 was discharged to home, but a review of their MDS assessments showed no documentation of a completed discharge MDS. Similarly, Resident #77 was discharged to another facility, and Resident #78 was discharged to home, with both lacking documentation of completed discharge MDS assessments. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the facility follows the RAI manual, which mandates that a Discharge MDS must be completed within 14 calendar days after discharge. However, the facility did not have a specific policy for MDS completion, relying solely on the RAI manual guidelines.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Tripoli
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillcrest Home | 8.3 mi | ★★★★★ | 0 | 0 |
| Denver Sunset Home | 9.7 mi | ★★★★★ | 2 | 0 |
| Woodland Terrace | 12.8 mi | ★★★★★ | 2 | 0 |
| Shell Rock Senior Living | 17 mi | ★★★★★ | 13 | 0 |
| Pillar Of Cedar Valley | 17 mi | ★★★★★ | 13 | 0 |
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