Metropolis Rehab & HCC

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jul 10, 2026

  A. Based on observation, interview, and record review the facility failed to ensure residents were free from neglect for 1 (R1) of 5 residents reviewed for abuse in a sample of 15. This failure resulted in a protracted period of time with unmanaged pain with R1 calling 911 a total of 5 times requesting an ambulance due to new onset severe pain to R1's right hip that had a nondisplaced right femur fracture found 6 days prior. The calls took place over a period of 2 hours and 3 minutes, during this time the nurse caring for R1 was called by the police dispatcher and said R1 was confused, had an affinity for pain medication, and there was no reason for R1 to be transferred to the hospital. […]

• Immediate jeopardy, isolatedF678Jul 10, 2026

  Based on interview and record review the facility failed to initiate Cardio-Pulmonary Resuscitation (CPR) timely for 1 (R1) of 4 residents reviewed for death in a sample of 15. This failure resulted in a delay in providing immediate emergency basic life support including CPR after finding R1 in his wheelchair with no pulse and no respirations. After CPR was initiated, R1 was transferred via ambulance to the local hospital and pronounced dead. The Immediate Jeopardy began on [DATE] at approximately 5:30 PM when R1 was found unresponsive in his room. V45 (Administrator), V42 (Regional Director of Operations), V18 (Regional Clinical Director), and V46 (Regional [NAME] President of Operations) were notified of the Immediate Jeopardy on [DATE] at 2:53 PM. […]

• Immediate jeopardy, isolatedF580Apr 3, 2026

  Based on interview and record review, the facility failed to notify a medical provider of elevated blood glucose levels for 1 (R4) of 3 residents reviewed for glucose monitoring. This failure resulted in R4 having blood glucose levels greater that 600 putting R4 at risk to develop Diabetic Ketoacidosis (DKA) which could result in coma and possible death.The Immediate Jeopardy began on 3/2/26 at approximately 8:00 AM when R4's blood glucose reading was not obtained and sliding scale insulin was not administered per Physician orders. […]

• Actual harm, isolatedF602Aug 10, 2026

  Based on interview and record review the facility failed to ensure residents were free from misappropriation of resident funds for 1 (R6) of 3 residents reviewed for theft in a sample of 22. This failure resulted in R6 experiencing feelings of stress, vulnerability, worry, and disappointment/feeling taken advantage of. This Past Non-Compliance occurred between 6/21/26 and 6/26/26. The Findings Include: 1. R6's Resident Face Sheet documents that R6 was admitted to the facility on [DATE] with diagnosis that include cerebral infarction, chronic obstructive pulmonary disease, major depressive disorder, anxiety, and polyneuropathy. R6's Minimum Data Set (MDS) assessment dated [DATE] documents a Brief Interview Mental Status score of 15, indicating R6 is cognitively intact. […]

• Actual harm, isolatedF689Aug 10, 2026

  Based on interview and record review, the facility failed to safely transport a resident in a wheelchair for 1 (R12) of 3 residents reviewed for accidents in the sample of 22. This failure resulted in R12 falling out of the wheelchair and acquiring a laceration to her forehead resulting in 2 sutures being placed.This past noncompliance occurred between 5/31/2025 and 6/9/2025.Findings included:R12's admission Record documented an admission date of 9/9/2024 with diagnoses including Alzheimer's disease, unspecified, dysphagia, oropharyngeal phase, diseases of lips, muscle weakness, unspecified osteoarthritis, unspecified site, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits.R12's Minimum Data Set (MDS) dated [DATE] documented under C0100:… […]