Metro West Nursing and Rehab Center

In the surveyor’s words

From the most serious findings on record at Metro West Nursing and Rehab Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF550Aug 28, 2025

  Based on observation, interview, and record review, the facility failed to promote a dignified existence during dining for cognitively impaired residents in the special-focus dining area and failed to maintain dignity for one resident during transport through facility hallway, (#104), of a total sample of 43 residents.Findings: 1. Resident #123 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including aphasia (loss of speech), hemiplegia and hemiparesis (partial paralysis) following cerebral infarction affecting right dominant side, dysphagia (trouble swallowing) and unspecified dementia. […]

• No harm, potential for more than minimal, patternF867Aug 28, 2025

  Based on interview, and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures for medication administration were sustained. Findings:A review of the facility's QAPI plan revised October 2024, stated for their purpose, that it provided guidance for their overall quality improvement program and that the Administrator would ensure that the QAPI plan was reviewed minimally on an annual basis by the QAA committee and conduct at least one distinct performance improvement project annually. Ongoing revisions would be made to the plan, as the need arose, to reflect current practices within the center. […]

• No harm, potential for more than minimal, patternF623Feb 22, 2024

  Based on interview, and record review, the facility failed to provide written Notification of Transfer or Discharge forms to the residents or their representative for 2 of 3 residents reviewed for hospitalization s out of a total sample of 47 residents, (#28 and #52). Findings: 1. Resident #28 was admitted to the facility on [DATE] with diagnoses including quadriplegia, intracranial injury with loss of consciousness, thrombocytopenia, encephalopathy, and gastrostomy malfunction. Review of the resident's medical record revealed a nursing progress dated 02/16/24 that noted the resident's gastrostomy tube was displaced. He was transferred to the hospital on 2/17/24 by non-emergency transportation for replacement. […]

• No harm, potential for more than minimal, patternF759Feb 22, 2024

  Based on observation, interview, and record review, the facility failed to prevent medication administration error rate of 5% or greater for 4 of 4 residents sampled for medication administration, (#3, #41, #77, #204). There were 8 medication errors in 27 opportunities for a medication error rate of 27%. Findings: 1. Resident #41 was admitted to the facility on [DATE] with diagnoses that included hypertension, schizophrenia, major depressive disorder, and type II diabetes mellitus. On 02/21/24 at 9:21 AM, Registered Nurse (RN) G, was by her medication cart preparing to administer morning diabetic medications. She stated it was her regular process to obtain blood sugars and administer insulin to all diabetic residents on her assignment first before administering all other medications. […]

• No harm, potential for more than minimal, patternF812Feb 22, 2024

  Based on observation, record review, and interview the facilty failed to ensure dishes and eating utensils were sanitized to prevent foodborne illness. Findings: On 2/19/24 at 10:33 AM, Dietary Aide A was observed at the dishmachine, washing the breakfast dishes. The Aide stated the dishmachine was low temperature and utilized a chlorine base chemical for sanitation. A minimum of 50 parts per million (PPM) for the sanitizer level was required. She explained she tested the sanitizer solution with a test strip, when she started washing the dishes, and the sanitizer was at 75 ppm. A rack of dishes came out of the machine and the Dietary Technician used a test strip to determine if the chemical sanitation solution was at the appropriate level. […]