Metropolis Rehab & HCC

Inspectors wroteA. 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on interview and record review the facility failed to seek timely medical treatment and complete physician ordered laboratory testing for 1 (R13) of 5 residents reviewed for quality of care in a sample of 15. This failure resulted in R13 experiencing respiratory distress with Acute Hypoxic Respiratory Failure with oxygen saturations at 60-70%.

Inspectors wroteBased on interview and record review the facility failed to provide adequate pain control for 1 (R1) of 3 residents reviewed for pain control out of a sample of 15. This failure resulted in R1 being in excruciating pain for 2 hours and 3 minutes and calling 911 a total of 5 times requesting an ambulance.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medical Director attended the scheduled Quality Assurance meetings. This failure has the potential to affect all 64 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff were trained on the required annual trainings. This has the potential to affect all 64 residents currently residing at the facility.

Inspectors wroteBased on interview and record review that facility failed to ensure Uniform Practitioner Orders For Life-Sustaining Treatment (POLST) status reflected resident wishes as desired throughout the Electronic Health Record and available for staff to access for 1 (R1) of 6 residents reviewed for advanced directives in the sample of 15.

Inspectors wroteBased on interview and record review the facility failed to notify the physician with a change of condition for 2 of 4 (R1 and R12) residents reviewed for change of condition in the sample of 15. Findings Include: 1. R1's admission Record documented an admission date of 5/20/26 with diagnoses including fracture of unspecified part of neck to right femur, periprosthetic fracture around internal prosthetic right hip joint, pain in right hip, chronic pain syndrome, and reduced mobility. R1's Minimum Data Set, dated [DATE] documents a Brief Interview on Mental Status (BIMS) assessment documented a score of 0, indicating severe cognitive impairment. On 6/23/26 at 8:33 PM, V44 (Licensed Practical Nurse/ LPN) said she was the nurse caring for R1 on the night of 5/22/26. V44 said R1 was alert and oriented to person, place, and time. [...]

Inspectors wroteBased on interview and record review the facility failed to report an allegation of staff to resident abuse immediately to the administrator and to the state agency (Illinois Department of Public Health) for 1 of 6 residents (R4) reviewed for abuse and neglect in the sample of 15.

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate allegations of abuse for 2 of 6 (R4 and R11) residents reviewed for abuse in the sample of 15. Findings Include:1. R4's admission Record documented an admission date of 3/9/26 with diagnoses including dependence on renal dialysis, muscle weakness, and need for assistance with personal care. R4's 6/8/26 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating R4 was cognitively intact. R4's Care Plan Report documented a revised 6/8/26 Focus area . has a behavior problem yells out frequently for staff and at times cursing at staff. Resident curses staff & residents. Makes accusations about staff and missing items. (R4) has a cell phone & has been provided with the person to contact if he has a concern. Resident can become physically aggressive with staff. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent, identify, and treat Moisture Associated Skin Damage (MASD) and failed to follow physician orders for lab testing after a change in condition for 2 (R1 and R2) of 3 residents reviewed for change in condition in a sample of 7. This failure resulted in R2 developing wounds that caused pain due to MASD.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide prescribed pain medication to 1 (R5) of 3 residents reviewed for medication administration in a sample of 7. This failure resulted in R5 experiencing lower back pain that radiated down her legs causing increased pain and insomnia.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer an antianxiety medication for 1 (R4) of 3 residents reviewed for medication administration in a sample of 7. This failure resulted in R4 developing withdrawal symptoms including insomnia, sweating, and shaking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meals were served at the scheduled times posted. This failure has the potential to affect all 62 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure timely acquisition of medication refills for 2 (R4 and R5) of 3 residents reviewed for medications in a sample of 7.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain effective sanitizer levels to sanitize food contact surfaces and failed to maintain kitchen equipment in a safe and sanitary condition. This failure has the potential to affect all 64 residents residing in the facility.

Inspectors wroteBased 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. V1 (Administrator), V11 (Assistant Director of Nursing/ ADON), V2 (Director of Nursing/ DON), V12 (Licensed Practical Nurse/ LPN/ Wound Nurse), V22 (Regional Clinical Director), and V23 (Regional Director of Operations) were notified of the Immediate Jeopardy on 3/20/26 at 9:06 AM. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents are free from significant medication errors for 5 (R4, R5, R9, R12, and R11) of 8 residents reviewed for medication administration in a sample of 14. This failure resulted in R9 experiencing a lack of sleep and feeling exhausted throughout the day.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide enough staff to perform Activities of Daily Living (ADL) care for dependent residents for 2 (R9 and R14) of 3 residents reviewed for ADL care in a sample of 14. This failure has the potential to affect all 13 residents residing on the 100 hall.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer medications within the ordered times and had a medication error rate of 96.8% medication error rate for 4 (R5, R11, R12, and R13) of 8 residents reviewed for medication administration.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide Activities of Daily Living (ADL) care for dependent residents for 1 (R9) of 3 residents reviewed for ADL care for dependent residents in a sample of 14.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow accepted standards of practice in maintaining infection control while providing incontinence care to 1 (R5) of 3 residents reviewed for Activities of Daily Living (ADL) in a sample of 14.

Inspectors wroteBased on interview, observation, and record review the facility failed to provide enough staff to meet the needs of the residents timely. This failure has the potential to affect all 62 residents residing at the facility.

Inspectors wroteBased on interview, observation, and record review the facility failed to provide drinks with meals for 4 (R1, R2, R3, and R4) of four residents reviewed for hydration in a sample of 8.

Inspectors wroteBased on interview, observation, and record review the facility failed to update and implement interventions to care plans for one (R1) of three residents reviewed for care plans in a sample of 8.

Inspectors wroteBased on interview, observation and record review the facility failed to provide and implement preventative measures and interventions for one (R3) on one resident reviewed for falls in a sample of three.

Inspectors wroteBased on interview and record review, the facility failed to treat residents with dignity and respect related to timely response to requests for assistance, valuing residents' private space, and refraining from practices that have the potential to feel demeaning or intimidating for 6 (R4, R8, R9, R10, R33 and R37) of 6 residents reviewed for resident rights in the sample of 46. This failure resulted in R8 experiencing feeling vulnerable, belittled, and intimidated and would cause a reasonable person to feel frustration and humiliation when R4 was put to bed without the opportunity to toilet and subsequently was incontinent. Findings Include: 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from staff abuse for 2 of 3 residents (R6 and R19) reviewed for abuse in the sample of 46. This failure resulted in R19 being spat in the face by a staff member which would cause a reasonable person to experience feelings of humiliation, anger and fear and resulted in staff verbally abusing R6 causing R6 to be visibility upset and fearful. Findings Include:1. The facility Final Reportable for R19 dated 10/02/25 documents under Complete Description of Occurrence: Initial Report: Initial: Abuse Coordinator was notified on 10/2/2025 at around 10:30pm about an alleged incident that took place between a staff member and resident, (R19). Staff were immediately suspended. Police, Family Representative and Physician were notified. Immediate investigation was initiated. Final: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician orders were accurate and implemented for recommended changes in treatment after a hospitalization and a fall, and failed to assess and treat lymphedema/wounds per physicians orders for 3 of 3 residents (R6, R7, R20) reviewed for quality of care/treatment in a sample of 46. This failure resulted in R6 struggling to breathe, causing anxiety, sleep disturbance, and significant discomfort due to recommended medications changes not being administered/implemented to treat newly diagnosed congestive heart failure. This failure also resulted in R7's developing redness, increased swelling, tenderness, and altered mental status and R7's subsequent hospitalization with a diagnosis of cellulitis and septic shock.

Inspectors wroteBased on observation, interview and record review the facility failed to provide the prescribed diets, nutritional supplements and the appropriate portion sizes according to the approved menus for 7 of 7 residents (R2, R3, R13, R15, R18, R19 and R42) reviewed for weight loss in a sample of 46. This failure further contributes to continued harm to R3 and R18, who are currently considered severely thin and underweight.

Inspectors wroteBased on interview and record review the facility failed to provide pain medications for pain management for 3 of 3 residents (R4, R5, and R31) reviewed for pain in the sample of 46. This failure resulted in R4 and R31 not having the medications available used to treat their pain resulting in uncontrolled pain. Findings Include:1. R4's admission Record with a print date of 10/01/25 documents R4 was admitted to the facility on [DATE] with diagnoses that includes polyneuropathy. R4's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 03, indicating R4 has a severe cognitive deficit. R4's current Care Plan documents a Focus area of (R4) has pain. Date Initiated: 01/22/2025. This Focus area includes the intervention of, Evaluate the effectiveness of pain interventions. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to 1. ensure medications were available to be administered as ordered, 2. ensure medications were administered timely, and 3. ensure medications were stored in a secure area for 6 of 6 residents (R4, R5, R19, R31, R35, and R45) reviewed for pharmacy services in the sample of 46. This failure resulted in R4 and R31 not receiving their pain medication and R4 and R31 crying with uncontrolled pain. Findings Include:1(a). R4's admission Record with a print date of 10/01/25 documents R4 was admitted to the facility on [DATE] with diagnoses that includes polyneuropathy. R4's MDS (Minimum Data Set) dated 8/29/25 documents a BIMS (Brief Interview for Mental Status) score of 03, indicating R4 has a severe cognitive deficit. R4's current Care Plan documents a Focus area of (R4) has pain. Date Initiated: 01/22/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient staff were available to meet the needs of residents in a timely manner. This has the potential to affect all 74 residents residing at the facility. Findings Include:1. R4's admission Record with a print date of [DATE] documents an admission date of [DATE] and included diagnoses of pressure ulcer, acute kidney failure, dementia, osteoporosis, chronic kidney disease, hypertension, glaucoma, muscle weakness, and reduced mobility. R4's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 03, indicating R4 has severe cognitive impairment. This same MDS documented R4 is dependent on staff for toileting hygiene and requires substantial/maximal assistance for transfers. [...]

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure the facility employed certified dietary staff in the kitchen. This failure has the ability to affect all 74 residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide sufficient and competent dietary staff to carry out the functions of the food and nutrition service. This failure has the potential to affect all 74 residents residing at the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure snacks were available and meals were served within the required timeline. This failure has the potential to affect all 74 residents residing at the facility. Findings Include:The facility Resident Matrix dated 10/15/25 documents 74 residents reside at the facility. 1. R21's admission Record with a print date of 10/22/25 documents R21 was admitted to the facility on [DATE] with diagnoses that include diabetes. R21's MDS (Minimum Data Set) dated 8/14/25 documents a BIMS (Brief Interview for Mental Status) score of 09, which indicates a moderate cognitive deficit. R21's current Care Plan documents a Focus area of, .Dietary Date Initiated: 10/22/2025. This Focus area includes the intervention of, .I prefer snacks between meals. I love cheese and crackers. Date Initiated: 10/08/2024. [...]

Inspectors wroteBased on interview, observation, and record review the facility failed to keep equipment functioning properly to ensure sanitation of dishware. This failure has the potential to affect all 74 resident residing at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to keep residents warm after showering and failed to provide nail care upon request for 6 of 7 residents (R3, R4, R6, R10, R25, R38) reviewed for self-determination in the sample of 46.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure incontinence care was provided timely and residents who required assistance with showering/bathing received showers for 6 (R1, R4, R5, R7, R22 and R38) of 6 residents reviewed for activities of daily living (ADL's) in the sample of 46. Findings Include:1. R1's admission Record with a print date of 10/23/25 document an admission date of 9/28/21 and included diagnoses of neurocognitive disorder with Lewy bodies, altered mental status, abnormal posture, muscle weakness, and unspecified psychosis. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 00, indicating R1 has a severe cognitive deficit. This same MDS documents R1 is dependent on staff for toileting hygiene and requires substantial/maximal assistance for toilet transfer. [...]

Inspectors wroteBased on interview, observation, and record review the facility failed to follow the facility menu for 9 (R4, R6, R7, R8, R10, R13, R15, R18, and R42) of 9 residents reviewed for dining in the sample of 46.

Inspectors wroteBased on interview, observation, and record review the facility failed to provide food that was palatable and at an appetizing temperature for 12 (R4, R5, R6, R7, R8, R9, R10, R11, R12, R14, R15, R25) of 12 residents reviewed for food service in a sample of 46.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide preferred items, substitutions, and to follow resident's outlined food preferences for 6 (R3, R5, R6, R8, R10, and R11) of seven residents reviewed for meal preferences and substitutions in a sample of 46.

Inspectors wroteBased on interview and record review the facility failed to provide needed incontinence supplies for 3 of 4 (R1, R7, R38) incontinent, dependent residents reviewed for supplies in the sample of 46.

Inspectors wroteBased on interview, and record review the facility failed to ensure allegations of abuse were reported to the Administrator/Abuse Coordinator for 1 of 3 (R6) residents reviewed for abuse in the sample of 46. Findings Include:R6's admission Record with a print date of 10/01/2025 documents R6 was admitted to the facility 2/6/25 with diagnoses that include acute respiratory failure, heart failure, chronic obstructive pulmonary disease, aortic valve stenosis, dementia, anxiety disorder, major depressive disorder, and cognitive communication deficit. R6's MDS (Minimum Data Set) dated 8/15/25 documents R6 is independent with making consistent/reasonable decisions, with no cognitive impairment documented. R6's current Care Plan was reviewed with no Focus area related to abuse and/or behaviors documented. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure allegations of abuse were thoroughly investigated for 1 of 3 (R6) residents reviewed for abuse in the sample of 46. Findings Include:R6's admission Record with a print date of 10/01/2025 documents R6 was admitted to the facility 2/6/25 with diagnoses that include acute respiratory failure, heart failure, chronic obstructive pulmonary disease, aortic valve stenosis, dementia, anxiety disorder, major depressive disorder, and cognitive communication deficit. R6's MDS (Minimum Data Set) dated 8/15/25 documents R6 is independent with making consistent/reasonable decisions, with no cognitive impairment documented. R6's current Care Plan was reviewed with no Focus area related to abuse and/or behaviors documented. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from significant medication errors for 3 of 3 residents (R5, R19, and R35) reviewed for medication administration in the sample of 46. Findings Include:1. R5's admission Record with a print date of 10/01/25 documents R5 was admitted to the facility on [DATE] with diagnoses that include cerebral infarct, heart failure, anemia, chronic obstructive pulmonary disease, adult failure to thrive, diabetes, and polyneuropathy. R5's Minimum Data Set (MDS) dated [DATE] documents R5 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R5 is cognitively intact. R5's current Care Plan documents a Focus area of, (R5) has Diabetes Mellitus. (R5) is non-compliant with her diet. Date Initiated: 05/31/2022. This Focus area includes the intervention of, Diabetes medication as ordered by doctor. [...]

Inspectors wroteBased on interview, observation, and record review the facility failed to provide supplements as order for wound healing for one resident (R4) of one resident reviewed for supplements for wound healing in a sample of 46.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a functional call system in a bathroom for 1 of 1 resident (R29) reviewed for functional call lights in the sample of 46.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain floors in a clean and sanitary manner. This has the potential to affect all 74 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from abuse for two of four residents (R1 and R4) reviewed for abuse on the sample list of eleven. Findings Include:1. R1's electronic health record (EHR) documented R1 has resided at the facility since 5/3/22. R1's EHR documented R1 has diagnoses including, but not limited to cerebral infarction, major depressive disorder, muscle wasting and atrophy, difficulty in walking, and dysphagia. R1's most recent Minimum Data Set (MDS) dated [DATE] documented R1 has a brief interview for mental status (BIMS) score of 9 indicating R1 is not cognitively intact. R1's MDS also documented R1 is mostly a partial to moderate assistance for all her activities of daily living (ADLs) except a few indicating R1's weakness and difficulty walking. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free from verbal and physical abuse from staff for 1 of 9 (R1) residents reviewed for abuse in the sample of 9.

Inspectors wroteBased on interview and record review, the facility failed to ensure Practitioner Orders for Life-Sustaining Treatment (POLST) status reflected resident wishes as desired throughout the Electronic Health Record for 1 (R74) of 18 residents reviewed for advanced directives in the sample of 38.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide therapeutic diets as ordered for 1 (R13) of 6 residents reviewed for dietary supplements in the sample of 38. Findings Include: R13's admission Record documented an admission date to the facility of 2/23/2024. Diagnoses listed include but not limited to unspecified dementia, severe with agitation, polyosteoarthritis, feeding difficulties, unspecified, dysphagia, and weakness. R13's Minimum Data Set (MDS) dated [DATE], under section C documented that R13 has a Brief Interview for Mental Status (BIMS) score of 03, indicating R13 is severely cognitively impaired. R13's Order Summary Report dated 1/17/2023 documented under Dietary-Supplements, ice cream one time a day for nutrition. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide urinary catheter care per current infection control standards for 1 (R57) of 3 residents reviewed for urinary tract infections in the sample of 38.

Inspectors wroteA. Based on observation, interview and record review the facility failed to provide assistance in a manner to prevent falls for 2 (R5 and R10) of 6 residents reviewed for falls in a sample of 16. This failure resulted in R10 sustaining a large intracranial hematoma, left eyebrow laceration and a left periorbital hematoma and R5 sustaining a skin tear to right shin and right shoulder along with a forehead laceration requiring 4 sutures.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean homelike environment in rooms of 3 (R7, R5 and R6) of 8 residents reviewed for housekeeping in the sample of 8.

Inspectors wroteBased on interview and record review, the facility failed to provide twice weekly showers for one of one resident (R49) reviewed for ADL (Activities of Daily Living) in the sample of 41.

Inspectors wroteBased on interview and record review, the facility failed to add interventions to prevent falls for one of two residents (R22) reviewed for falls in the sample of 41.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide catheter care in accordance with current standards of practice for 1 of 2 residents (R24) reviewed for catheter care in the sample of 41.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer a residents' tube feeding accordance with physician's orders for 1 of 1 resident (R47) reviewed for tube feeing in the sample of 41.

Inspectors wroteBased on observation, interview, and record review the facility failed to label insulin vials and insulin pens with the date of opening for 2 of 5 (R49 and R52) residents reviewed for medication storage out of a sample of 41.

Inspectors wroteBased on interview and record review the facility failed to provide peritoneal dialysis treatments for 1 of 2 residents (R1) reviewed for dialysis in a sample of 7. This failure resulted in R1 presenting with a change in condition of confusion and being admitted to the hospital with lethargy and receivng hemodialysis during R1's hospital stay.

Inspectors wroteBased on interview and record review, the facility failed to safely transport a resident in a wheelchair to prevent an accident for 1 of 3 residents (R1) reviewed for accidents in the sample of 6. This failure resulted in R1 receiving an 8 cm (centimeter) laceration over his right eye requiring 10 staples.

Inspectors wroteBased on observation interview and record review the facility failed to ensure adequate supervision was implemented to prevent elopement for 2 of 3 (R1 and R2) residents reviewed for elopement in the sample of 7. This past non-compliance occurred between 07/23/23 until 11/10/23. Findings Include: 1. R1's admission Record with a print date of 12/04/23 documents R1 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's Disease, dementia, major depressive disorder, anxiety, dizziness, and reduced mobility. R1's MDS (Minimum Data Set) dated 10/10/23 documents R1 has a severe cognitive impairment. R1's current undated Care Plan documents a Focus area of (R1) is an elopement risk/wanderer AEB (as evidenced by) due to his wandering activity and a desire to get outside. This Focus area has an initiation date of 10/18/22. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's wheelchair had foot rests in place when transporting a resident outside of the facility for 1 (R1) of 7 residents reviewed for accidents. This failure resulted in R1's foot dropping and pulling back under the wheelchair resulting in a closed fracture of distal end of the right tibia. This past non-compliance occurred between 10/12/23 and 10/18/23.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pressure ulcers were assessed, treated, and interventions were implemented timely for 1 of 3 (R66) residents reviewed for pressure ulcers in the sample of 36. This failure resulted in R66 developing a Stage 3 Pressure Ulcer to R66's coccyx which was up to 1 week old before it was assessed and treated. Findings Include: R66's facility admission Record with a print date of 5/24/23 documents R66 was admitted to the facility on [DATE] with diagnoses of fracture of femur, cirrhosis of liver, fracture of ribs, neurocognitive disorder, diabetes, and fracture of vertebra. R66's MDS (Minimum Data Set) dated 4/23/23 documents a BIMS (Brief Interview for Mental Status) score of 02, which indicates R66 has a severe cognitive deficit. [...]

Inspectors wroteBased on interview and record review the facility failed to provide dependent residents with bathing assistance/showers for 1 of 6 residents (R21) reviewed for activities of daily living in a sample of 36.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide a resident with a history of weight loss, nutritional supplements as ordered for 1 of 10 (R17) residents reviewed for nutritional supplements in a sample 36.