Metropolis Rehab: Feeding Failures Caused Actual Harm - IL
Federal inspectors flagged the failure on November 17, 2025, rating it as causing actual harm to the resident, identified in records as Resident 19. The deficiency fell under F0692, which covers a facility's obligation to ensure residents receive the nutrition their conditions require.
Resident 19 was admitted to the facility on December 22, 2023. His diagnoses filled a long list: end-stage renal disease, dependence on renal dialysis, dementia, severe cognitive impairment, dysphagia, combined systolic and diastolic heart failure, and gastroesophageal reflux disease. A cognitive assessment placed his BIMS score at 6 out of 15, indicating severe impairment. He could not advocate for himself at the table or anywhere else.
His dietary orders were specific. As of March 31, 2025, he had a standing order for fortified foods every day and evening shift. As of April 18, 2025, he was on a no-added-salt diet with mechanical soft texture, meaning food had to be prepared in a particular way to reduce his choking risk. Both orders carried no end date. They were still active when inspectors arrived.
His care plan reflected how seriously the facility understood his swallowing problem. It listed interventions going back to October 2024: follow the prescribed diet, monitor for shortness of breath and choking and labored breathing and lung congestion, watch for difficulty swallowing, food pocketing, prolonged swallowing time, coughing, throat clearing, drooling. The documentation was detailed. The swallowing risk was known.
What the care plan did not include was any focus area for nutrition. Not a line.
Then there was what the dietitian wrote. A dietary note dated October 18, 2025, recorded that Resident 19's weight had held between 127.2 and 136.4 pounds since February and was within his usual body weight range. No pressure wounds. Labs from September showed an elevated glucose of 181.5. The note concluded that his diet order had been individualized based on intake trends, and listed his current diet as regular with regular texture and sugar-free condiments.
Regular texture. Not mechanical soft.
The order in his chart required mechanical soft. The dietitian's note described regular texture. His documented swallowing disorder had not changed. His care plan still listed interventions for choking and pocketing food. And at some point during his lunch, according to the inspection record, he was not receiving any fortified pudding.
For a man on renal dialysis with heart failure and severe cognitive impairment, the gap between what was ordered and what was happening is not a paperwork problem. Dialysis patients have narrow nutritional margins. Fortified foods are not a preference. They are ordered because the body, under the strain of kidney failure and the dialysis process itself, cannot afford to go without them. His swallowing disorder meant that even getting adequate calories into him required careful preparation of every bite.
The facility had the orders. They had the care plan. They had a dietitian conducting chart reviews. And still, on the day inspectors observed, Resident 19 had no fortified pudding with his lunch, and his nutrition had no place in the document that was supposed to guide his daily care.
Inspectors rated the violation as causing actual harm, not as a risk of harm, not as a technical deficiency. Actual harm, to a man who could not tell anyone what he was or wasn't being given to eat.
His BIMS score of 6 meant he could not reliably communicate his needs, track his own meals, or notice when something was missing from his tray. He depended entirely on the people around him to follow what was written in his chart. On at least one documented occasion, they did not.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Metropolis Rehab & Hcc from 2025-11-17 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
METROPOLIS REHAB & HCC in METROPOLIS, IL was cited for violations during a health inspection on November 17, 2025.
Federal inspectors flagged the failure on November 17, 2025, rating it as causing actual harm to the resident, identified in records as Resident 19.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.