Metropolis Rehab & Hcc
METROPOLIS REHAB & HCC in METROPOLIS, IL — inspection on May 26, 2026.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
medical provider was new and had rounded on his own or with floor nurses. V2 was asked who is
responsible.On 5/20/26 at 2:47 PM, V6 was asked if R1's labs that had been drawn earlier that day
V6 said while she was talking to the laboratory technician they asked if V6 wanted the urine culture faxed over too and V6 told them she had not sent any urine. V6 said she was told R1 had a urine culture from 5/10/26 and V6 told them to fax it as well because she was not aware of a urinalysis.On 5/26/26 at 2:07 PM, V11 (Physician/ Medical Director) said he expected the facility to follow Physician orders. V11 said he expected staff to review Physician progress notes and if it was unclear what labs the Physician wanted, the facility should contact them to get clarification.The facility's 2/2026 Skin Identification, Evaluation, and Monitoring Policy documented in part . A licensed nurse will evaluate skin integrity through a physical skin evaluation upon admission, weekly, and when a significant change is identified.
Licensed nurses will evaluate the resident's risk for skin breakdown using the Braden Risk Assessment tool upon admission. and when a significant change is identified.
Licensed Nurse Weekly: A.
Complete a Weekly Skin Check to evaluate for changes in skin integrity. B.
Document in medical record the finding of weekly skin assessment. b. If new wound is identified: i.
Initiate protective dressing. ii.
Notify health care provider of findings and for further treatment orders.
C.
Document evaluation in the medical record.
Identification of Skin Conditions. B.
Moisture Associated Skin Damage (MASD) is a general term for skin damage that occurs when the skin is exposed to moisture such as perspiration, urine or feces or both. for a prolonged period. b. MASD can be presented as mild, moderate, or severe and can occur in all client age groups; i.
Mild MASD presents as irritation and inflammation of the skin. ii.
Moderate to severe MASD presents with blistering and erosion and/ or denudation of the epidermal layer to the dermis. c.
Secondary fungal and bacterial infections may occur.
Interventions and Prevention: Skin.
Incontinence Management. e.
Utilize properly fitting incontinence briefs that are absorbent and wick moisture away from the skin on incontinent residents.The facility's 12/2024 Significant Condition Change and Notification policy documented in part . To ensure that the resident's family and/ or representative and medical practitioner are notified of resident changes such as those listed below: A significant change in the resident's physical, mental or psychosocial status (See below for examples). new wounds, bruises or skin tears. change in level of consciousness such as agitation, lethargy, sudden lack of responsiveness or manic behavior. a need to significantly alter treatment.
When any of the above situations exists, the licensed nurse will contact the resident's representative and their medical practitioner. the medical practitioner will e contacted immediately for any emergencies regardless of the time of day.
Non-emergency notifications may be made the next morning if the situation occurs on the late evening or night shift.
All significant changes will be recorded. in the resident record.
Change of condition is reviewed by DON or designee for the continued need for additional documentation.
145813 05/26/2026
Metropolis Rehab & Hcc 2299 Metropolis Street Metropolis, IL 62960
order must include medication name, dosage, route of administration, frequency, and any necessary
the provided instructions and guidelines.Staff members administering the medication must adhere to
the dateof administration, time of administration, name of medication, dosage, route, and reason for administration.
Controlled substances must be signed out on an inventory sheet and counted during shift change with on-coming nurse.
Resident's response to medication must be documented within 30 - 60 minutes, along with any observed or reported side effects or reactions.
Significant changes in the resident's condition in response to the PRN medication must be documented and reported to the appropriate licensed healthcare professional immediately.
There was no reference to the management of pain documented in this policy.
145813 05/26/2026
Metropolis Rehab & Hcc 2299 Metropolis Street Metropolis, IL 62960
Summary Report documented a 12/31/25 order for Tramadol 50 mg (milligrams), 1 tablet by mouth every 8 hours as needed for pain. On 5/20/26 at 2:56 PM, the medication cart that served R5's room was observed to have no tramadol tablets present for R5. V6 (Registered Nurse/RN) said R5 did not have any tramadol available. V6 said R5 had asked for a tramadol that morning and V6 told R5 we don't have any for her. V6 said the facility had emailed V11 (Physician/ Medical Director) again that morning requesting a tramadol prescription for R5 but had not heard back. V6 said she had not called the on-call medical provider because she was waiting to see if V11 responded. V6 said she could not obtain any tramadol out of the emergency backup supply because R5 did not have an active order for tramadol. R5's Controlled Substances Proof of Use documented 15 tablets of tramadol 50 mg were delivered to the facility on 5/2/26, with the last administration of those 15 tablets being given on 5/15/26. R5's Medication Administration Record (MAR) dated 5/1/26 - 5/31/26 documented 5/15/26 was the last administration of R1's PRN (as needed) tramadol 50 mg until 5/21/26.
The MAR shows there were no administrations of R1's PRN tramadol from 5/16/26 through 5/20/26. On 5/20/26 at 2:10 PM, V12 (Regional Clinical Consultant) was alerted of R5 not having any tramadol available and of V6's interview (above) and V12 sighed heavily and said she would have V6 call the on-call provider immediately to obtain a prescription. V12 stated the on-call provider should have already been contacted. On 5/21/26 at 1:53 PM, R5 said she can't go without pain medication and the days the facility did not have any tramadol for her she could not sleep because she was hurting so bad and at times was in tears. On 5/26/26 at 2:07 PM, V11 (Physician/ Medical Director) said if a resident reported pain and did not have an active prescription for pain medications, he expected staff to call him and he would sign the order or to call the on-call medical provider company to get a prescription.
The facility's pharmacy policy and procedures were requested from V12. V12 provided a document/sign from the facility's contracted pharmacy dated 2024 that documents the heading Medication Not Available.
What Now? and further states Check: Check eMAR (electronic medication administration record) for last order/fill date.
Verify transmission to pharmacy for new orders and refills.
Check fax machine or eMAR for communication from pharmacy.
Obtain: Obtain from (emergency medication kit), if available.
Call: Call the pharmacy for order status (e.g., prior authorization pending, refill too soon, order clarification).
Notify prescriber if dose is missed.
Follow facility process if additional notifications are required.
Documentation: Document steps taken to obtain medication and prescriber notification.
Prevention: Reorder 3-5 days prior to last remaining dose.
Check pharmacy placard for cut-off times.
Receive delivered medications in eMAR.The undated facility policy titled Medication Administration Policy for Senior Living was also provided.
Under PRN Medication Guidelines documents Medication administration shall be documented promptly and accurately, including the date of administration, time of administration, name of medication, dosage, route, and reason for administration.
145813 05/26/2026
Metropolis Rehab & Hcc 2299 Metropolis Street Metropolis, IL 62960
medication for 1 (R4) of 3 residents reviewed for medication administration in a sample of 7.
This
shaking.Findings include:R4's admission Record documented an original admission date of 11/8/23 with diagnoses including early onset cerebral ataxia, anxiety disorder, and depression. R4's 4/8/26 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating R4 was cognitively intact.R4's Care Plan Report documented a revised 1/7/26 focus area of R4 has anxiety and currently takes anxiety medications with a 2/12/24 intervention of administer medication as ordered and monitor/ document for side effects and effectiveness.R4's Order Summary Report documented a 3/30/26 order for Ativan 0.5 mg 1 tablet every morning and at bedtime for anxiety.On 5/21/26 at 1:32 PM, R4 said a couple weeks ago the facility ran out of her Ativan and did not tell R4. R4 said she had experienced withdrawal symptoms like sweating and shaking, feeling like she was very hot and then would be ice cold. R4 said there were several nights she couldn't sleep and felt like my insides were trembling. R4 said she had been taking Ativan for a long time. R4 said she was not sure of the name of the nurse she talked to about her symptoms, but that was the nurse that informed R4 the facility had run out of R4's Ativan and would try to reach the doctor to get it refilled.On 5/19/26 at 11:31 AM, V9 (Licensed Practical Nurse/ LPN) said R4 did not have any Ativan for several days and V2 (Director of Nursing/ DON) was aware. V9 said R4 was very tearful during that time but was not aware of R4 having any withdrawal symptoms.On 5/19/26 at 12:22 PM, V2 said she was not aware R4 was not receiving her Ativan.On 5/26/26 at 2:07 PM, V11 (Physician/ Medical Director) said if a resident has been taking Ativan and stops it suddenly the resident could experience withdrawal symptoms such as headache, muscle pains, nausea and vomiting, tremors, etc.R4's Controlled Substances Proof of Use form documented the facility received 4 Ativan 0.5 mg tablets on 5/3/26 with the last tablet being administered on 5/5/26 at 8:00 AM.R4's Controlled Substance Proof of Use form documented the facility received 6 Ativan 0.5 mg tablets on 5/12/26 with the first one being administered on 5/13/26 at 8:00 AM, 8 days after the last dose of Ativan was administered indicating R4 had missed 15 doses of Ativan.R4's 5/1/26-5/31/26 Medication Administration Record (MAR) documented R4's Ativan 0.5mg tablet had been administered from 5/5/26-5/13/26 twice a day, the morning dose on 5/9/26 documented a 5 with the key indicating hold, the morning and even dose on 5/10/26 documented a 6 with the key indicating other- see progress note, the bedtime dose on 5/11/26 documented a 6, and the morning dose on 5/12/26 documented a 6.The undated facility policy titled Medication Administration Policy for Senior Living under Medication Administration documents Medications should be administered according to the ?five rights' of medication use: right resident, right drug, right time, right dose, and the right route.
145813 05/26/2026
Metropolis Rehab & Hcc 2299 Metropolis Street Metropolis, IL 62960
requests.
Suitable and nourishing alternative meals and snacks must be provided for residents who
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on
scheduled times posted.
This failure has the potential to affect all 62 residents residing in the facility.
Findings include: R2's admission documented an admission date of 7/19/17. R2's Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. R5's admission Record documented an admission date of 12/30/25.
R5's MDS assessment dated [DATE] documented a BIMS score of 15, indicating R5 was cognitively intact. R7's admission Record documented an admission date of 11/25/25. R7's MDS assessment dated [DATE] documented a BIMS score of 14, indicating R7 was cognitively intact. On 5/20/26 at 2:47 PM, R5 and R7 stated they always eat in their room and the meals are always delivered late. R7 said breakfast was usually on time but the noontime and evening meals are sometimes 30 minutes to an hour and a half late. On 5/21/26 at 1:47 PM, R2 said she always eats in the big dining room and the noontime and evening meals are often served late. On 5/21/26 at 12:08 PM, V10 (Licensed Practical Nurse/ LPN) said meals are served late often. V10 said a couple weeks prior to this investigation a meal had been served an hour and a half late. V10 said there is a posted schedule of when meals are to be served. V10 said she was not sure why meals were served late so often. On 5/20/26 at 12:35 PM, V8 (Certified Nursing Assistant/ CNA) stated the noontime meal was over 30 minutes late at the time of this interview. V8 said this was a common occurrence and when meals are late it makes staff get behind in completing other tasks.
The facility's undated The Dining Experience posted documented the noontime meal was to be served as follows: Small Dining Room at 12:00 PM, Large Dining Room at12:20 PM, 400 Hall Cart at 12:35 PM, 300 Hall Cart at 12:40 PM, 100 & 200 Hall Cart at 12:50 PM. On 5/20/26 at 12:33 PM, residents were sitting in the small dining room waiting for the noontime meal to be served. On 5/20/26 at 12:49 PM, the meal cart for the small dining room arrived, 49 minutes late, and staff started serving resident meal trays. On 5/20/26 at 1:10 PM, the 400 hall meal cart arrived, 35 minutes late. On 5/20/26 at 1:17 PM, the 300 hall meal cart arrived, 37 minutes late. On 5/20/26 at 1:32 PM, the 100 and 200 hall meal cart arrived, 42 minutes late.
The last meal tray on the 100 and 200 hall meal tray cart was delivered at 1:38 PM. On 5/21/26 at 12:07 PM, residents were sitting in the small dining room waiting for the noontime meal to be served. At 12:30 PM, the small dining room meal cart arrived, 30 minutes late.
The facility's 5/19/26 Assignment Location List Report documented 62 residents residing in the facility.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.