Charlottesville Health & Rehab: Medication Errors - VA
The medication errors occurred at Charlottesville Health & Rehabilitation Center during an 11-day stay in August. Federal inspectors found that staff failed to properly review the resident's medications on admission, leading to inappropriate psychiatric drug treatment.
Resident #5 arrived at the facility on August 4 with a hospital discharge summary showing that delirium had resolved. The resident had no documented history of depression. Yet the nurse practitioner ordered amitriptyline for depression, along with trazodone and Seroquel.
The resident's son requested discontinuation of all three psychiatric medications during visits on August 11 and August 13. The nurse practitioner documented his request in progress notes both days and stated it was her intent to stop the drugs.
She never did.
The medications continued until the resident was discharged on August 15. For four days after the family's request, staff administered psychiatric drugs to a person who had no psychiatric diagnosis requiring them.
When inspectors interviewed the facility's MDS Coordinator on September 4, she confirmed the problem. The licensed practical nurse said she had reviewed the resident's diagnoses and "was unable to find depression, or delirium." She explained that the nurse practitioner had assigned the depression diagnosis despite no history in the hospital record.
The MDS coordinator noted that delirium appeared in the nurse practitioner's progress notes, but the hospital discharge summary showed it had resolved. That's why delirium wasn't placed on the official diagnosis list.
A regional director participating by phone told inspectors that amitriptyline was listed on the hospital record, but no diagnosis was documented with it.
The nurse practitioner's explanation revealed the depth of the oversight failure. During her September 5 interview, she claimed the depression diagnosis "came from the hospital." But when pressed, she admitted she couldn't find it anywhere in the hospital paperwork.
"When reviewing the history and physical and the hospital paperwork, she was unable to find the diagnosis of depression, but believed that was how she obtained it," inspectors wrote.
The nurse practitioner then shifted responsibility to nursing staff. She told inspectors that "the nursing staff entered that diagnosis with the medication on admission, and she did not catch that the resident had no history of depression when she signed off on the paperwork."
This admission highlighted a fundamental breakdown in the medication review process. The facility's own policy requires physicians or nurse practitioners to review patient medical plans at each visit and approve admission orders after reviewing patient information from the discharging physician.
The policy states that "a discharging physician will provide patient information and orders to the facility at the time of admission" and that "the patient's admission information is to be reviewed, and orders approved by the attending physician."
None of this happened properly for Resident #5.
The case illustrates how medication errors can cascade through a nursing home stay. First, staff entered a diagnosis that didn't exist to justify a medication that shouldn't have been prescribed. Then the nurse practitioner signed off without catching the error. Finally, when family members specifically requested the medications be stopped, the facility ignored them for four days.
Amitriptyline, one of the drugs inappropriately continued, is a tricyclic antidepressant with significant side effects in elderly patients, including confusion, falls, and heart rhythm problems. Seroquel is an antipsychotic that carries FDA warnings about increased death risk in elderly patients with dementia.
The MDS Regional Director's observation was particularly telling. The hospital had listed amitriptyline on the medication record but provided no diagnosis to support its use. This should have been a red flag requiring clarification before continuing the drug.
Instead, facility staff created a diagnosis out of thin air.
The violation affected what inspectors classified as "few" residents, suggesting similar medication review failures may have occurred with other patients. The harm level was rated as "minimal harm or potential for actual harm," but the case demonstrates how easily inappropriate psychiatric medications can be administered in nursing homes.
Federal inspectors notified the administrator, director of nursing, and regional clinical care coordinator about their findings on September 4. The facility provided no additional information to address the concerns.
For Resident #5's family, the experience meant watching their loved one receive unnecessary psychiatric medications for nearly two weeks, including four days after they specifically asked for the drugs to be stopped. The resident was discharged still taking medications prescribed for conditions that didn't exist.
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.
The medication errors occurred at Charlottesville Health & Rehabilitation Center during an 11-day stay in August.
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.