Metropolis Rehab: Ativan Withdrawal Harm From Stock Failure - IL
The resident, identified in inspection records as R4, had been living at Metropolis Rehab & Health Care Center since November 2023. She was cognitively intact, according to a mental status assessment completed in April 2026. Her diagnoses included anxiety disorder and depression, and she had been prescribed Ativan — a benzodiazepine used to treat anxiety — twice daily, every morning and every night.
On May 5, the facility gave her the last tablet it had on hand. It didn't receive more until May 12. The first new dose wasn't administered until May 13 at 8:00 AM, eight days after the last one.
She missed 15 doses.
Speaking with an inspector on May 21, R4 described what those days felt like. She said she felt very hot and then would be ice cold. She said there were several nights she couldn't sleep. She said it felt like her insides were trembling. She had been taking Ativan for a long time, she said, and nobody at the facility had told her the medication was gone. She learned what had happened only after she went to a nurse to describe her symptoms, and that nurse told her the facility had run out and would try to reach the doctor to get it refilled.
R4 said she wasn't sure of the nurse's name.
The facility's own medical director, interviewed on May 26, confirmed what the records already showed. If a resident has been taking Ativan and stops suddenly, the physician said, they could experience withdrawal symptoms including headache, muscle pains, nausea and vomiting, and tremors.
That is what R4 experienced. Alone, without warning, without anyone monitoring her for what was happening.
A licensed practical nurse, interviewed two days before the inspection closed, acknowledged that R4 had gone without Ativan for several days and said the Director of Nursing was aware. The nurse said R4 was very tearful during that time. The nurse said she was not aware R4 had experienced withdrawal symptoms.
The Director of Nursing, interviewed the same morning, said something different. She said she was not aware R4 was not receiving her Ativan at all.
The medication administration records tell their own story. Between May 9 and May 12, the entries for R4's Ativan doses were marked with codes indicating the doses were held, or flagged as "other, see progress note." The controlled substance log shows four tablets arrived on May 3. The last one was given May 5. Six more arrived May 12. The gap between them: eight days, fifteen missed doses, one resident shaking through the nights in her room.
The inspection was filed as a complaint investigation. The level of harm was documented as actual harm.
What the records do not show is anyone checking on R4 during those eight days with the knowledge that her medication had run out. No documented monitoring for withdrawal. No documented call to the physician before the supply ran dry. No documented conversation with R4 explaining what was happening to her body and why.
R4 told the inspector she had been taking Ativan for a long time. She knew something was wrong. She went to find a nurse. The nurse told her the facility had run out.
That was how she found out.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Metropolis Rehab & Hcc from 2026-05-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 16, 2026 · Our methodology
METROPOLIS REHAB & HCC in METROPOLIS, IL was cited for violations during a health inspection on May 26, 2026.
The resident, identified in inspection records as R4, had been living at Metropolis Rehab & Health Care Center since November 2023.
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.