Dept of State Hospitals - Metropolitan SNF

In the surveyor’s words

From the most serious findings on record at Dept of State Hospitals - Metropolitan SNF, in the surveyor’s own words.

• Immediate jeopardy, widespreadF607Mar 7, 2026

  Based on observation, interview, and record review, the facility failed to develop written policies and procedures (P&P) that clearly defined all forms of abuse to include resident-to-resident abuse. This failure resulted in the facility's inability to recognize and identify three of three sampled incidents involving resident-to-resident physical and alleged sexual assault as abuse when1. Resident 2 punched Resident 1 in the face while Resident 1 slept and Resident 2 alleged sexual assault and stated he [Resident 1] tried to have sex with me.2. Resident 3 kicked Resident 4 in the buttocks and Resident 4 punched Resident 3 in the face three times.3. […]

• Immediate jeopardy, isolatedF698Dec 8, 2025

  Based on observation, interview, and record review the facility failed to provide ongoing assessment, monitoring and implementation of interventions for one of 21 sampled residents (Resident 10) when on 10/23/2025, Resident 10 was diagnosed with a blood clot in his arteriovenous fistula (AV fistula- surgical connection of an artery and a vein that allows for blood to flow directly to provide a long-term access point for filtering blood in patients with kidney disease) and the physician had an order to check the AV fistula for bruit and thrill (bruit is a swooshing sound heard over a blood vessel, while a thrill is the vibrating or buzzing sensation felt over the same vessel, both indicate a strong blood flow of an AV fistula), on the left upper arm every shift, since 11/24/2025. […]

• Actual harm, isolatedF600Mar 7, 2026

  Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse (any intentional act causing injury or trauma to another person through bodily contact) by another resident for one of six sampled residents (Resident 1) when Resident 2 punched Resident 1, in the face while Resident 1 slept. The facility failed to implement adequate supervision, environmental interventions, and behavioral interventions for Resident 2, who the facility had previously identified as a moderate risk for violence against others to prevent foreseeable harm. […]

• Actual harm, isolatedF686Dec 8, 2025

  Based on observation, interview, and record review, the facility failed to implement their policy to ensure the provision of pressure-injury (damage to skin from pressure) prevention, monitoring, and treatment were consistent with professional standards of practice for two of 21 sampled residents (Resident 30 and Resident 4). 1.Resident 30's buttocks were previously identified as areas of impaired skin integrity and were not monitored for two months. In addition, Resident 30's Low Air Loss mattress (LAL-pressure relieving air mattress) was not set to the accurate weight in accordance with the manufacturer's instructions. 2.Resident 4's ischial tuberosity (sit bone) was previously identified as an area of impaired skin integrity and was not monitored for three weeks. […]

• Actual harm, isolatedF600Jul 2, 2024

  Based on observation, interviews and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for 1 of 3 sampled residents (Resident 1) when Resident 2 assaulted Resident 1. This failure resulted in physical harm to Resident 1 when he sustained multiple facial lacerations, contusions, and a nasal bone fracture. Findings: During a review of Resident 1 (R1)'s Face sheet, (undated), the record indicated that R1 was admitted to the facility on [DATE], with a history of diagnoses that included: unspecified neurocognitive disorder (decreased mental function due to a medical disease other than psychiatric illness), unspecified displaced fracture of second cervical vertebra (break in the second bone of the neck) .with routine healing,… […]