Metropolis Rehab: Medications Left Unattended in Rooms - IL
The aide, identified in inspection records as V61, told investigators that nurses at the facility routinely left medications on top of the medication cart and in residents' rooms, unattended. When he spotted them, he said, he always carried them to a nurse. He didn't want to think about what would happen if he didn't.
Federal inspectors visited the facility on November 17, 2025, responding to a complaint. What they documented was a pattern, not a single lapse.
A second nursing assistant, V51, told inspectors on October 16 that he didn't know the agency nurse on duty but could name two licensed practical nurses, V56 and V53, who left medications sitting on top of the medication cart and in resident rooms without supervision. He said it without apparent hesitation.
Four days later, a third aide, V62, described the same thing. Nursing staff left pills on residents' bedside tables for the resident to take on their own. The pills, V62 said, just sat there on the table, unattended.
None of the residents described in the report had been evaluated or approved for self-administration. The facility's own medication policy states that self-administration requires a written physician's order, a formal evaluation at admission, and reassessments every six months. There is no indication any of that happened here.
The regional pharmacy's policy and procedure manual, dated July 2024, is explicit on the mechanics: during medication rounds, the cart stays in the doorway with open drawers facing inward, nothing on top, and the nurse must keep it visible at all times. Medications are never to be left in a resident's room without a specific order permitting it. The facility's own undated medication administration policy echoes this, requiring secure locked storage and staff confirmation that the resident has actually received each dose.
The Director of Nurses, V2, told inspectors on October 21 that leaving medications unattended was not acceptable. She said it plainly, as a statement of policy. She did not appear to dispute that it was happening.
CMS rated the harm level as actual harm, meaning inspectors concluded that real injury, not just the risk of it, had occurred.
The specific nature of that harm is not detailed in the portion of the inspection report made available. What the record does show is that multiple staff members, working different shifts and identified separately, described the same unsafe practice. A nursing assistant had appointed himself an informal safeguard, walking the halls and collecting medications that should never have been left there in the first place.
Metropolis Rehab & HCC sits at 2299 Metropolis Street in Metropolis, Illinois, a small city in the far southern corner of the state. The inspection was conducted in response to a complaint, not as part of a routine survey cycle.
The three aides who spoke to investigators did so over a span of five days in October. Their accounts were consistent. Two of them named specific nurses. One of them had been quietly cleaning up the problem on his own, apparently for long enough that it had become routine.
He told inspectors he always took the pills to a nurse when he found them. The question the inspection report leaves open is what happened on the days he didn't find them first.
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.
When he spotted them, he said, he always carried them to a nurse.
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.