Forest Health & Rehab: Drug Diversion by LPN - VA
That description, offered by at least two residents during interviews conducted in April 2025, pointed directly to a licensed practical nurse who was already on suspension by the time investigators came looking. She has since resigned.
The complaint inspection, completed September 13, 2025, documented what the facility itself had uncovered and reported: a suspected case of drug diversion, meaning a staff member was taking residents' prescribed medications, almost certainly controlled substances, for purposes other than administering them to the patients in her care.
The residents who spoke to the director of nursing or her designee on April 15 were direct about what they had experienced. Each said, in their own words, that they never received their nighttime medications when that particular nurse was on duty. The inspection record does not name the residents, but it notes they were among those on the LPN's assignment who were able to be interviewed. Their accounts were consistent. Their description of the nurse was specific enough to identify her without using her name.
Nobody had to guess who they meant.
Drug diversion in nursing homes is not a new problem, and it does not always get caught. It tends to surface in one of two ways: a pharmacist flags a discrepancy in controlled substance counts, or a resident notices they aren't getting relief and says something. In this case, it appears to have been the latter. The residents noticed. They remembered which nurse was working. And when someone finally asked, they answered.
The facility suspended the LPN after the allegation surfaced. The inspection record does not specify the exact date of suspension or what triggered the initial inquiry, but by April 14, the director of nursing had begun assessing every resident on the nurse's assignment for any change in condition that could have resulted from not receiving their prescribed medications. The review turned up no identified findings, meaning inspectors found no documented evidence that residents had been physically harmed by missing doses.
That conclusion carries its own weight. For residents dependent on scheduled pain medication, a missed dose is not an abstraction. It is hours of unrelieved pain, a disrupted night, a body that needed something and did not receive it because someone else took it. The inspection record does not detail what medications were involved or how many doses may have been diverted over what period of time. It records only that residents said it happened, that the nurse's description matched the suspended LPN, and that no measurable change in condition was identified afterward.
The facility's response, as documented in the corrective action plan signed by the administrator, director of nursing, assistant director of nursing, unit managers, and the social services director, moved on several fronts at once. All licensed nurses were educated on drug diversion and on the proper protocol for notifying the administrator when diversion is suspected. Staff across the facility were retrained on the abuse policy, with specific emphasis on misappropriation of resident property, which is the regulatory category under which drug diversion falls. The controlled substance inventory count sheets used at shift changes were revised, with a systemic change implemented to ensure proper documentation going forward.
The plan was signed and dated. The deadline for completion was April 21, 2025, one week after the resident interviews began.
Going forward, the director of nursing or her designee committed to auditing narcotic sheets weekly for twelve weeks, watching for signs of diversion. For four weeks, and then monthly for two months after that, staff would interview three residents at random to ask whether they were receiving their pain medications. Those audit results would go to the facility's quality assurance and performance improvement committee.
The facility also held an emergency QAPI meeting outside its regular schedule to address the situation.
When federal surveyors returned for the recertification inspection that ran from September 9 through September 13, 2025, they reviewed the corrective actions. They interviewed staff. They interviewed residents. They observed medication administration directly. The inspection record states that evidence confirmed the corrective actions had been implemented between April 14 and April 21, and that no further concerns related to misappropriation of resident property were identified. Staff and resident interviews revealed no new concerns. Observations of the medication pass showed nothing troubling.
The facility, in its own written conclusion submitted as part of the corrective action plan, stated that it takes the care and services of its residents very seriously and that it completed all necessary steps. The language is standard. What sits behind it is less so.
A licensed nurse, trusted with access to a medication cart and the care of residents who could not always advocate for themselves in real time, appears to have taken their medications. The residents who noticed did so because they felt the absence. They lay awake or in pain on nights when that nurse was working, and when someone finally sat down across from them and asked whether they were getting their medications, they said no, and they described exactly who was responsible.
The LPN is gone. The inspection found the corrective actions in place. The audit schedule is running. The controlled substance count sheets have been revised.
What the inspection record does not contain is any account of what those residents experienced on the nights their medications didn't come, or how many nights that was, or how long it went on before anyone outside their rooms knew to ask.
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.
Download the official CMS inspection PDF from Medicare.gov
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: September 22, 2026 · Our methodology
FOREST HEALTH & REHAB CENTER in LYNCHBURG, VA was cited for violations during a health inspection on September 13, 2025.
The residents who spoke to the director of nursing or her designee on April 15 were direct about what they had experienced.
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.