Forest Health & Rehab: Drug Diversion Allegations - VA
Both described her the same way. The Black nurse with braids on top of her head in a ball.
The nurse was an LPN. By the time investigators finished their interviews, she had been suspended. Then she resigned.
The complaint that triggered the investigation centered on a pattern, not a single missed dose. Residents weren't describing a night when something went wrong. They were describing something that happened consistently, reliably, whenever this particular nurse was on their assignment. The medications weren't being forgotten. They were being skipped.
What happens to a controlled substance that never reaches the patient it was signed out for is a question the inspection report does not answer directly. What it does describe is a facility that, once the allegation surfaced, moved quickly to contain the problem and document its response — and a surveyor who returned months later and found the corrective actions in place.
The Director of Nursing, or a designee, began interviewing residents on April 14 and 15, within days of the complaint coming forward. The focus was specific: had anyone experienced a change in condition that could be traced to not receiving prescribed medications? The facility found no identified findings. That phrasing is the clinical language of inspection reports, and it means what it says — no resident was found to have been harmed in a measurable way.
But the absence of documented harm is not the same as the absence of harm. When a patient does not receive a prescribed medication, particularly a controlled substance prescribed for pain, the gap between "no identified findings" and "no suffering" can be wide.
Staff who had worked alongside the LPN during the preceding 72 hours were interviewed about unusual behaviors and whether they had heard complaints from residents about their care. No negative findings emerged from those interviews either. There was, however, one consistent detail that did surface: the LPN had a pattern of taking excessively long breaks.
That detail sits in the report without further elaboration. Inspectors noted it. The facility noted it. No one drew a conclusion on paper. But in the context of an investigation into whether a nurse was diverting controlled substances from residents who needed them for pain, an employee who routinely disappeared for extended periods is not a minor administrative footnote.
Human resources reviewed the LPN's personnel file and the files of five other randomly selected employees to confirm they were in good standing. No negative findings there, either. The file review was a precaution, a way of checking whether something in the employment record should have flagged a problem earlier. Apparently nothing did.
The facility's plan of correction, signed by the administrator, the Director of Nursing, the Assistant Director of Nursing, two unit managers, and the Social Services Director, laid out a sequence of actions completed by April 21. All licensed nurses were educated on drug diversion and on the rights of residents to receive their medications. The education included instructions on when and how to notify the administrator if diversion is suspected. All staff were re-educated on the abuse policy, with specific emphasis on misappropriation.
The facility also changed its process for controlled substance inventory counts at shift change, implementing what it described as a systemic change requiring use of proper count sheets. Any staff member returning from paid time off or vacation would be educated on the new process before working. New hires would receive the same education during orientation.
The monitoring plan called for the Director of Nursing or a designee to audit random narcotic sheets weekly for twelve weeks, looking for signs of diversion. Three residents per week would be interviewed for four weeks, then monthly for two months, to confirm they were receiving their pain medications. Results would go to the facility's Quality Assurance Performance Improvement committee.
The facility also held an emergency QAPI meeting.
All of this happened between April 14 and April 21, 2025. Seven days from the first resident interview to a signed corrective action plan with a monitoring schedule attached.
When surveyors returned for the recertification survey in September, running from the 9th through the 13th, they reviewed what the facility had done. Staff interviews revealed no concerns related to misappropriation. Resident interviews revealed no concerns. Observations of medication administration revealed no concerns. The corrective actions had been implemented. The LPN was gone.
The violation was cited at the lowest level of harm: minimal harm or potential for actual harm, affecting few residents.
That designation matters for how the violation is categorized and what enforcement consequences, if any, follow. It does not resolve the underlying question of what happened to the medications that two residents say they never received.
Drug diversion in nursing homes is not rare. It is, by its nature, difficult to detect. A nurse who diverts a controlled substance from a resident typically signs the medication out of the controlled substance log as administered, creating a paper record that shows the drug reached the patient. The resident, particularly one who is elderly, cognitively impaired, or simply unaware of what they are supposed to receive, may not know to complain. Or may complain and not be heard.
What made this case visible was that two residents spoke up, and they said the same thing. Their accounts were specific enough to identify a single employee. That specificity is what moved the facility from a vague concern to a suspension.
The inspection report does not name the residents. It does not describe what medications they were prescribed, what conditions those medications were treating, or what those residents experienced on the nights they say they went without. It does not describe what the LPN said, if anything, before she resigned. It does not say whether the matter was referred to law enforcement or to the state nursing board.
What it says is that the facility took corrective action, that surveyors found the action sufficient, and that no further concerns were identified.
The two residents who told investigators they never got their medications when that nurse worked are still living at Forest Health & Rehab. The nurse who they described is not.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Forest Health & Rehab Center from 2025-09-13 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 28, 2026 · Our methodology
FOREST HEALTH & REHAB CENTER in LYNCHBURG, VA was cited for violations during a health inspection on September 13, 2025.
Both described her the same way.
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.