Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.Findings include:R1's admission
record documents an admission date of 12/07/23 with diagnoses including: Alzheimer's disease, dorsalgia,
type 2 diabetes mellitus, speech and language deficits following other cerebrovascular disease, bipolar
disorder, dementia, unsteadiness on feet, cognitive communication deficit, acute kidney failure, muscle
weakness, difficulty in walking, and depression. R1's Minimum Data Set, dated [DATE] documents a brief
interview of mental status (BIMS) of 09 indicating R1 is moderately impaired. An incident report sent to the
Illinois Department of Public Health with a final reportable date of 8/19/25 documents in part, . An allegation
of inappropriate staff behavior towards resident (R1) was reported to the Abuse Coordinator on 8/14/25.
Employee's (V6) CNA, (V5) CNA, (V4) LPN were immediately suspended, pending investigation . (V5),
C.N.A., reports that (R1) had feces on his hands, bed and body and was very agitated. (V6) entered the
room when she heard (R1) cursing. (R1) immediately used racial slurs towards (V6) once she entered the
room, because she was being rude to him. (V5), reports, (V6) placed her hands over (R1's) mouth to get
him to stop calling her the N word. (V6) exited the room, while I continued to care for (R1) and his
roommate . (V6) reports, I overheard (R1) hollering at (V5), C.N.A., I finished with the resident I was caring
for and went to check in to see if I could be of assistance. (R1) was soaked with urine and covered in feces
and refusing care. I attempted to calm him down when he started using racial slurs towards me, I then left
the room in frustration! Interview with (R1), he reports, a boy and girl came into his room and put him to
bed roughly and held him down. He said, it happened sometime after supper, unsure exact time. (R1)
denies anyone holding their hand over his mouth. (R1) denies injury, denies being scared to stay here and
feels safe .IDT (Interdisciplinary Team) met and determined to substantiate allegations of abuse towards
(V5), C.N.A. and (V6), C.N.A. for allegedly holding (R1) down to clean him up from where he was soiled and
for (V6) using a rude tone of voice towards him. On 08/17/25 at 3:41 PM, R1 stated she held his arms
down, he didn't want to go to bed. R1 stated, he doesn't remember her name, that girl, he knows what she
looks like. R1 stated then she got mad and she yelled at him. R1 stated she yelled he was going to bed and
he was to stop. He said he didn't want to, he tried to grab onto something. R1 stated that guy was there, he
wears a white thing on his head. R1 stated he usually goes to bed around 9 to 9:30 PM sometimes,10:00
PM. R1 stated sometimes he may lay down for a bit earlier. R1 stated he knows he is in a nursing home but
that does not give them the right to do that. R1 stated, he didn't tell anyone, he does want to get into
problems or get someone into trouble. R1 stated he was fine and did not feel afraid to stay at the facility.On
08/17/25 at 3:41 PM, R1 was sitting in his wheelchair on the back hall, he was pleasant and did not appear
in any distress. On 08/17/25 at 4:05 PM, V2 (Director of Nursing) stated they were notified of the allegation
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
145813
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145813
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/21/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Metropolis Rehab & Hcc
2299 Metropolis Street
Metropolis, IL 62960
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
concerning R1 on Thursday and V5 (Certified Nurse Aide), V6 (Certified Nurse Aide), and V7 (Licensed
Practical Nurse) were suspended pending the investigation. V2 stated, the investigation is ongoing.On
08/17/25 at 5:30 PM, V7 (Licensed Practical Nurse) stated, she came in to work the evening the incident
with R1 happened. V7 stated, she was in a resident's room just down from R1's room and she heard V6
yelling, stop and something like stop trying to get out of bed, then heard her say loudly, You are my problem
then she (V6) came out of R1's room. V7 stated, V5 and V6 did not know she was in a room nearby. V7
stated, she did not hear V5 yelling or sounding agitated. V7 stated, what she heard was later in the evening
around 9:00 PM. V7 stated, she had not heard anything with R1 earlier in the evening she only heard the
incident around 9:00 PM. V7 stated, she checked on R1 shortly after the incident and R1 stated he was
fine. V7 stated, she checked on R1 again a little later in the evening and he was sleeping.On 08/17/25 at
7:11 PM, V5 (Certified Nurse Aide/CNA) stated he was working the evening the incident happened with R1.
He was working the hall with V6 (CNA). Later in the evening R1 needed changed and cleaned up he had
feces on him. V5 stated, he was working on cleaning R1 up and he was having some behaviors but he was
still cooperating with him however he was yelling, but it was not bothering him. V5 stated he was just letting
R1 say whatever he wanted it was fine, R1 was still doing whatever V5 had asked him to do. V5 stated then
V6 (CNA) came into the room to help but she did not have any patience with R1 so he was getting more
agitated. V5 stated V6 was holding R1's arms down and covering R1's mouth with her arm to the point R1's
words sounded muffled. V5 stated he told V6 a couple times that he (V5) was fine and did not need her
help with R1. V5 stated, V6 was getting hateful and yelled at R1 to stop. V5 stated V6 did yell more than that
but he was more focused on her arm covering his mouth and that was bothering him (V5) and that is why
he kept telling her he didn't need her help. V5 stated, he has only worked at the facility for two weeks. V5
stated, he did not know he had two hours to report this to his supervisors, it was at the end of their shift and
he figured he would tell them when he came to work the next day. He came to work the next day and V6
was suspended so he was trying to cover the whole hall for a while and he was concentrating on the
residents' needs. Then he was told to talk V1 (Administrator) and he was suspended. He told them he did
not hold R1's arms down and he did not yell at R1. R1 was actually doing everything he asked and he was
getting him changed and cleaned up just fine.On 08/17/25 at 5:39 PM, V6 (Certified Nurse Aide) stated she
was in a room with another resident. V6 stated she could hear R1 yelling, R1 always yells at the workers.
V6 stated, she went to check on V5. V6 stated R1 seemed to get more agitated and she left to let him calm
down. V6 stated, she assisted another resident and heard R1 still yelling so she went back into the room to
see if V5 needed help. V6 stated, she never told R1 he had to go to bed, she never yelled at R1. R1 called
her a racial slur and she left the room and did not go back into the room. V6 stated, she typically doesn't
have too much to do with R1.On 08/17/25 at 4:17 PM, V9 (Licensed Practical Nurse) stated, she has never
had any problems with R1, sometimes when you go to get him up in the morning, he can be ornery but if
you just give him a minute and come back he is just fine. Typically, R1 is pleasant and jolly.On 08/17/25 at
4:09 PM V8 (Certified Nurse Aide) stated, she has not seen any staff being mean or yelling at any residents
personally. V5 and V6 are suspended but she has never worked with either of them. V8 stated, she has
taken care of R1 and he is pretty easy. V8 stated, she has never known R1 to say things that were not
true.The facility policy dated 03/2025 titled, Abuse, Prevention and Prohibition Policy documents:
Prevention: the resident has the right to be free from verbal, mental, sexual, exploitation, or physical abuse;
corporal punishment and involuntary seclusion. The owner, licensee, administrator, employee, or agent of
the facility shall not abuse or neglect a resident and much prohibit the misappropriation of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145813
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145813
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/21/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Metropolis Rehab & Hcc
2299 Metropolis Street
Metropolis, IL 62960
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600
resident property.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145813
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
FAQ · About this visit
Common questions about this visit
What happened during the August 21, 2025 survey of METROPOLIS REHAB & HCC?
This was a inspection survey of METROPOLIS REHAB & HCC on August 21, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at METROPOLIS REHAB & HCC on August 21, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect b..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.