Based on record review and interview the facility failed to keep Resident #38 free from a chemical restraint imposed for purposes of discipline when an antipsychotic medication was given without a physician order. The deficient practice put all one (1) resident that exhibit behaviors currently residing in the facility at risk for serious injury, serious harm, serious impairment, or death. Resident identifier: #38. Facility Census: 135. Findings included: a) Resident #38 During a complaint survey a review of Resident #38's nursing progress notes found: Nursing note dated 05/5/24 4:35 AM Came onto wing at 2:20, patient (pt) came out screaming and chasing the staff down the hallway because they wanted a regular diet, was told to go back to their room, patient went into the room and laid… …
F605 citations in West Virginia
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
West Virginia cites F605 less often than its own record predicts
0.26 times the national share — cited less often here than elsewhere.
Of every deficiency written in West Virginia in 2025, this is the portion that was F605.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What West Virginia surveyors wrote
F605 findings written in West Virginia, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on record review and staff interview, the facility failed to ensure as needed (PRN) orders for psychotropic medications were limited to 14 days, unless the prescribing practitioner documented a rationale to extend the medication and indicated a duration for the PRN order. This deficient practice had the potential to affect two (2) of five (5) residents reviewed for the care area of unnecessary medications. Resident Identifiers: #3 and #13. Facility Census: 15. Findings included: a) Policy and Health System Formulary Review The facility's policy titled, Psychotropic Medications - NCF [Nursing Care Facility], with effective date 04/21/17 and revision date 05/07/21, stated PRN (as needed) psychotropic medications would be ordered for no more than 14 days unless the practitioner felt it… …
The short window
Recent years
| Year | Share of West Virginia citations | vs expected |
|---|---|---|
| 2024 | 0.22% | 10.87× |
| 2025 | 0.18% | 0.26× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else West Virginia surveyors cite →
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