Charlottesville Health: Ignored Family Pleas - VA
They promised to discontinue the drugs. They never did.
Charlottesville Health & Rehabilitation Center continued administering three antipsychotic medications to the resident despite repeated family requests and a nurse practitioner's documented intent to stop them, according to a September 4 federal inspection.
The resident, identified as R5, exhibited an altered level of consciousness on August 9. His son reported the man was experiencing confusion severe enough that he asked if his son was inside the mirror during their visit that day.
The son immediately requested that staff discontinue three medications he believed were causing delirium: Amitriptyline, Trazodone and Seroquel. Staff held the medications for three days, obtained lab work that came back normal, then restarted all three drugs.
Two days later, on August 11, the son made the same request. The nurse practitioner documented his concerns and his plea to discontinue the psychotropic medications.
On August 13, the son tried again. The nurse practitioner wrote that the resident's son had requested discontinuation of the antipsychotic medications because his father was experiencing "increased confusion, agitation, and anxiety over the weekend." The practitioner documented her intent to discontinue the medications.
She never did.
The facility's own therapy director told inspectors the resident participated well in all three therapy disciplines during this period. He ambulated several times daily, used exercise equipment, and completed his sessions despite becoming fatigued.
But the medications continued.
Federal inspectors discovered additional medication errors when they reviewed the resident's admission paperwork. Two antipsychotic drugs had been added to his admission orders that weren't on his hospital discharge medication list. The facility's policy requires that discharge medications be reviewed and approved by the attending physician at admission.
When inspectors confronted administrators about the violations on September 4, they learned the facility had no policy governing antipsychotic medication use. The regional director of clinical services confirmed no such policy existed.
The violations occurred despite the facility's written policy stating that medications must be administered only by licensed personnel authorized by state law and "in accordance with written orders of the prescriber." The policy also requires that discharge physicians provide patient information and orders at admission, and that admission information be reviewed and approved by the attending physician.
None of that happened correctly for R5.
The resident's experience illustrates a broader problem with psychotropic drug use in nursing homes, where such medications are sometimes used inappropriately to manage behaviors rather than treat specific psychiatric conditions. Federal regulations require facilities to ensure residents receive appropriate treatment and that unnecessary drugs are avoided.
R5's son made his concerns clear across multiple days in August. He could see his father's deteriorating mental state. He specifically identified the three medications he believed were causing the delirium. He asked repeatedly for them to be stopped.
The nurse practitioner listened. She documented his requests. She wrote her intent to discontinue the problematic drugs.
But R5 continued receiving Amitriptyline, Trazodone and Seroquel. His confusion persisted. His family's pleas were ignored despite being carefully documented in his medical record.
The facility provided no additional information to inspectors about why the medications were never discontinued despite the documented intent to stop them, or why no policy existed to guide staff in psychotropic medication decisions.
R5's son had done everything a family member could do. He identified the problem, made specific requests, and persisted when his initial plea was ignored. The nursing home's own practitioner agreed with his assessment and documented plans to help.
The medications kept coming anyway.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Charlottesville Health & Rehabilitation Center from 2025-09-04 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 20, 2026 · Our methodology
CHARLOTTESVILLE HEALTH & REHABILITATION CENTER in CHARLOTTESVILLE, VA was cited for violations during a health inspection on September 4, 2025.
They promised to discontinue the drugs.
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.