Based on record review, and staff interview the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents. As a result, a resident accessed and ingested medications that caused clinically significant adverse consequences necessitating hospitalization to stabilize Resident #100. This failed practice resulted in actual harm to Resident #100 Facility census 112. Findings included: On 08/23/2020 at 7 AM the facility discovered three (3) missing medication cards containing narcotic medications: Resident #98 had one (1) card of Oxycodone 10 mg., with 20 pills. Resident #82 - two (2) cards containing Norco 5/325 mg. (One (1) card containing 15 pills and the second card containing 30 pills.) A total of 65 missing narcotic medications. …
F761 citations in West Virginia
Drug labeling and storage · Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
West Virginia cites F761 less often than its own record predicts
0.34 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 F761.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What West Virginia surveyors wrote
F761 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 observations, policy review, World Health Organization(WHO) review, staff interview, the facility failed to ensue that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles to including appropriate accessory and cautionary instructions and the expiration date when applicable. This had the potential to affect more than an isolated number of residents. Facility census: 74. a) Findings include: On 08/24/26 at 12:20 PM, one vial of Tubersol/Tuberculin Purified Protein Derivative (PPD) injectable vial was observed in the medication refrigerator. No date was observed on the box or vial. The vial was half empty of liquid serum. …
The short window
Recent years
| Year | Share of West Virginia citations | vs expected |
|---|---|---|
| 2023 | 2.27% | 0.72× |
| 2024 | 1.64% | 0.53× |
| 2025 | 1.09% | 0.34× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else West Virginia surveyors cite →
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