Meadowbrook Acres: Accident Hazard Violations - WV
Federal inspectors found the 58-bed facility failed to follow its own care plans for applying bed rails during a November complaint investigation. The violations affected residents who relied on the rails for basic mobility and positioning.
Resident 49 had doctor orders for bilateral half-rails to assist with bed mobility and transfers. Her care plan specifically listed the rails as an intervention for "deconditioning, weakness, pain" to aid in "turning and repositioning."
When inspectors observed her room on November 4 at 10:45 AM, no side rails were in place.
The Director of Nursing confirmed the next morning that the resident had no side rails on her bed, despite the written orders and care plan requirements.
Resident 30's situation was similar but had persisted longer. Her fall care plan, implemented in August, required "half bilateral side rails to head of bed for increased independence with positioning and personal care."
Nearly three months later, inspectors found her lying in bed with no side rails in place. The Director of Nursing acknowledged during a November 4 interview that the rails were missing despite the care plan.
Resident 19 faced the same gap between written orders and actual care. Her care plan, completed October 13, approved "bilateral quarter side rails for assisting with repositioning and bed mobility."
When inspectors checked her room November 6 at 9:40 AM, no rails were installed. Hours later, the Director of Nursing admitted the side rails weren't in place as ordered.
The inspection revealed a systematic breakdown in following care plans at the facility. Each resident had documented medical needs for the rails, approved orders from healthcare providers, and specific care plan interventions. Yet none received the equipment they were supposed to have.
Bed rails serve critical safety and mobility functions for residents with weakness, deconditioning, or fall risks. They provide support for turning, repositioning, and getting in and out of bed independently. Without them, residents may struggle with basic movements or require additional staff assistance for tasks they could otherwise manage alone.
The violations occurred despite clear documentation in each case. Resident 49's care plan explicitly connected her need for rails to her physical limitations. Resident 30's plan linked the rails to fall prevention and independence. Resident 19's order was approved specifically for mobility assistance.
Federal inspectors classified the violations as having potential for minimal harm affecting some residents. The facility houses 58 residents total, with inspectors reviewing bed rail orders for 11 residents and finding three cases of non-compliance.
The Director of Nursing's acknowledgment of each violation during inspector interviews suggests facility leadership was aware the care plans weren't being followed. In each case, she confirmed that ordered rails were not in place when they should have been.
Care plan compliance represents a fundamental nursing home responsibility. Federal regulations require facilities to develop comprehensive care plans meeting all resident needs, then implement those plans with measurable actions and timetables.
At Meadowbrook Acres, the gap between planning and implementation left three residents without equipment their doctors and care teams determined they needed for safe mobility and positioning.
The inspection occurred following a complaint, though the report doesn't specify the nature of the original concern that triggered the federal review. Inspectors completed their work November 6, documenting the care plan failures across multiple residents and timeframes.
Each resident affected had different underlying conditions requiring bed rail assistance, from general weakness and deconditioning to fall risk factors. But all three experienced the same result: care plans that weren't implemented despite clear orders and documented need.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Meadowbrook Acres from 2025-11-06 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
MEADOWBROOK ACRES in CHARLESTON, WV was cited for violations during a health inspection on November 6, 2025.
Federal inspectors found the 58-bed facility failed to follow its own care plans for applying bed rails during a November complaint investigation.
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.