Metropolis Rehab: Resident Left 5 Days Without Pain Meds - IL
The resident, identified in inspection records as R5, approached the inspector on May 20, 2026, and asked if something could be done about her medications. She said the nurses kept telling her they had nothing to give her. She said they had contacted the pharmacy and the doctor. She said she was still waiting.
R5 had a standing order for tramadol 50 mg, written back in December 2025, allowing her to receive one tablet every eight hours as needed for pain. The facility received a supply of 15 tablets on May 2. The last one was given to her on May 15. From May 16 through May 20, the medication administration record shows no tramadol was given at all.
The registered nurse on duty, identified as V6, confirmed to the inspector that R5 had no tramadol available and that R5 had asked for one that very morning. V6 said she had told R5 there was nothing to give her. She said the facility had emailed the medical director, V11, again that morning. She had not called the on-call provider. She was waiting to see if the email got a response.
There was an emergency backup supply in the facility. V6 said she could not access it for R5 because R5 did not have an active order for tramadol, despite the December 2025 order sitting in R5's file.
When the facility's regional clinical consultant, V12, was informed of the situation at 2:10 PM that afternoon, she sighed heavily and said she would have V6 call the on-call provider immediately. V12 said the on-call provider should have already been contacted.
The next day, May 21, R5 told the inspector she couldn't go without pain medication. She said on the days the facility had nothing for her, she could not sleep because she was hurting so badly and at times was in tears.
The medical director, V11, told inspectors on May 26 that if a resident reported pain and didn't have an active prescription, he expected staff to call him and he would sign an order, or they should call the on-call provider company to get a prescription. He said this plainly, as a matter of course, as if it were obvious.
It apparently was not obvious to the staff managing R5's care that week.
The facility's own contracted pharmacy had posted written guidance on exactly this situation. The document, headed "Medication Not Available. What Now?", laid out a clear sequence: check the electronic record, verify the order was transmitted, check the fax machine, obtain from the emergency kit if available, call the pharmacy, notify the prescriber if a dose is missed. The instructions also specified that facilities should reorder three to five days before the last remaining dose runs out.
R5's supply ran out May 15. Nobody appears to have started reordering three to five days before that. Nobody called the on-call provider when the email to V11 went unanswered. Nobody accessed the emergency kit. The guidance existed. The phone existed.
R5 has a history that makes unmanaged pain particularly serious: she has muscle weakness, unsteadiness on her feet, hypokalemia, hypoxemia, and a prior history of transient ischemic attack. She is cognitively intact, with a perfect score on the mental status screening administered to her. She knew exactly what was happening to her and she told anyone who would listen.
She was still in tears at night.
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 R5, approached the inspector on May 20, 2026, and asked if something could be done about her medications.
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.