Meadowbrook Acres: Care Quality Deficiencies - WV
Federal inspectors found the 58-bed facility systematically ignored its own written care plans during a November complaint investigation. The violations affected residents who needed the rails to turn in bed, reposition themselves, and transfer safely.
Resident #49 had bilateral half rails ordered to assist with bed mobility and transfers. Her care plan, designed to address weakness and deconditioning, specifically called for the rails "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's bed lacked the prescribed equipment entirely.
Resident #30's situation proved equally troubling. His fall care plan, implemented in August, required "half bilateral side rails to head of bed for increased independence with positioning and personal care." The intervention was designed to help prevent additional falls while allowing him greater autonomy in bed.
Inspectors found him lying in bed without any rails on November 4 at 10:40 AM. The Director of Nursing acknowledged during an interview five minutes later that the facility had failed to install the equipment specified in his care plan.
The pattern continued with Resident #19, whose care plan from October 13 approved "bilateral quarter side rails for assisting with repositioning and bed mobility." Two weeks after the order was written, inspectors observed the resident in bed on November 6 with no rails present.
Again, the Director of Nursing admitted during a 1:45 PM interview that the prescribed equipment was missing.
The violations represent a fundamental breakdown in care plan implementation. Federal regulations require nursing homes to develop comprehensive care plans and follow through with the interventions they prescribe. Bed rails, when properly ordered, serve as assistive devices that help residents maintain independence and prevent injuries.
The missing equipment left residents without tools their medical teams determined were necessary for safe bed mobility. Resident #49, dealing with deconditioning and weakness, lacked the support structure designed to help her turn and reposition. Resident #30, already identified as a fall risk, went without the rails meant to give him "increased independence" while reducing injury potential.
Resident #19 similarly lost access to the positioning assistance doctors had specifically approved for his mobility needs.
The Director of Nursing's repeated acknowledgments suggest the facility was aware of the missing equipment but had not taken action to correct the deficiencies. The violations occurred across multiple residents over several months, indicating systemic rather than isolated failures.
Care plans serve as roadmaps for resident treatment, translating medical assessments into specific daily interventions. When facilities ignore their own written plans, residents lose access to prescribed care designed to maintain their safety and independence.
The inspection found the facility failed to implement care plans for three of eleven residents reviewed for bed rail compliance, a 27 percent failure rate among those examined.
Federal inspectors classified the violations as causing minimal harm or potential for actual harm, affecting some residents. The November 6 complaint investigation documented the care plan failures as part of a broader review of facility practices.
The missing bed rails represent more than administrative oversight. For Resident #49, struggling with weakness and pain, the absent rails eliminated a key tool for maintaining bed mobility. For fall-risk Resident #30, the missing equipment removed a safety measure specifically designed to prevent additional incidents while preserving his independence.
Resident #19 went without positioning assistance that medical staff had determined was necessary for safe bed mobility, leaving him to manage transfers and repositioning without the prescribed support structure.
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: July 29, 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 systematically ignored its own written care plans 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.