Meadowbrook Acres
Inspection Findings
F-Tag F0557
F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Based on observation, and staff interview the facility failed to provide residents with a dignified activity experience by passing medications during Bible Study. This failed practice was a random opportunity for discovery during the Complaint Survey. Resident identifier #9. Facility Census 58.Findings Include:a) Resident #9An observation on 11/04/25 at 2:18 PM, revealed the recreation room door to be closed and a sign that read, Bible Study on the closed door.Further observation revealed Registered Nurse (RN) #48, opening the closed door that read, Bible Study and administering Resident #9 a medication.During an
interview on 11/04/25 at 2:30, RN #48 stated, If we are running behind we give them during activities or in
the dining room. SA asked the RN if he was behind today and RN #48 stated, Not really, I just wanted to get done. SA then asked what medication did you give the resident? RN #48 replied, Baclofen.During an
interview on 11/04/25 at 3:14 PM, Activity Assistant (AA) #73 confirmed that the RN gave the medicine
during Bible Study and stated, They give medicines in all of our activities.A policy review on 11/04/25 at 3:30 PM, revealed a policy titled {Medication Administration}, {Policy Explanation and Compliance Guidelines}, under bulletin seven (7) reads; Provide Privacy
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/06/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Meadowbrook Acres
2149 Greenbrier Street Charleston, WV 25311
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0600
F 0600
since. The DON further stated, I noticed our policy had not been reviewed since 2013 and got us a new one.
Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/06/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Meadowbrook Acres
2149 Greenbrier Street Charleston, WV 25311
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0656
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Based on observation, record review and staff interview the facility failed to develop and implement the care plan for applying bed rails to the beds. This was true for three (3) of the eleven (11) residents that were reviewed for bed rails. Resident Identifiers: #49, #30 and #19. Facility Census: 58 Findings Include: a) Resident #49
On 11/04/25 at 10:10 AM record review of current orders for Resident #49 shows 1/2 bilateral upper siderails to assist with bed mobility and transfers.
On 11/04/25 at 10:20 AM review of the care plan for Focus (Residents name) hasd an ADL self care performance deficit related to deconditioning, weakness, pain. Resident #49s interventions./tasks show Bilateral 1/2 side rail to aid in turning and repositioning.
On 11/04/25 at 10:45 AM observation of Resident #49 shows she has no side rails in place at this time.
The above findings were confirmed with the Director of Nursing on 11/05/25 at 9:15 AM at which time she agreed there were no side rails present on the bed. b) Resident #30
A record review on 11/04/25 at 10:30 AM, revealed a fall care plan for Resident #30, that has an intervention implemented on 08/018/25 that reads as follows: Half bilateral side rails to head of bed for increased independence with positioning and personal care.
An observation on 11/04/25 at 10:40 AM, revealed Resident #30 lying in bed, no side rails in place per the care plan.
During an interview on 11/04/25 at 10:45 AM, The Director of Nursing (DON), confirmed that the side rails were not on Resident #30's bed as care planned. c) Resident #19
A record review on 11/05/25 at 12:25 pm, revealed a Care Plan order for Resident #19, completed on10/13/2025 that reads as follows: Resident #19 (name) has been approved for use of bilateral quarter side rails for assisting with repositioning and bed mobility.
An observation on 11/06/25 at 9:40 AM, revealed the resident lying in bed, no bilateral quarter side rails in place per order.
During an interview on 11/06/25 at 1:45 PM, The Director of Nursing (DON) acknowledged that the side rails were not in place as ordered for Resident #19.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/06/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Meadowbrook Acres
2149 Greenbrier Street Charleston, WV 25311
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
neurological assessments for Resident #23 for the unwitnessed fall on 10/31/25 and they should have been performed. c) Resident #19
A record review on 11/05/25 at 12:25 pm, revealed a Care Plan order for Resident #19, completed on10/13/2025 that reads as follows: Resident #19 (name) has been approved for use of bilateral quarter side rails for assisting with repositioning and bed mobility.
An observation on 11/06/25 at 9:40 AM, revealed the resident lying in bed, no bilateral quarter side rails in place per order.
During an interview on 11/06/25 at 1:45 PM, The Director of Nursing (DON) acknowledged that the side rails were not in place as ordered for Resident #19. b) Resident #30
A record review on 11/04/25 at 10:30 AM, revealed an order for Resident #30, dated 08/18/25 that reads as follows: Half bilateral side rails to head of bed for increased independence with positioning and personal care.
An observation on 11/04/25 at 10:30 AM, revealed the resident lying in bed, no half bilateral side rails in place per order.
During an interview on 11/04/25 at 10:45 AM, The Director of Nursing (DON) confirmed that the side rails were not in place as ordered for Resident #30 and stated, We did an audit a few weeks back and that is her new bed. I did not do a new assessment. I guess I dropped the ball on that one.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/06/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Meadowbrook Acres
2149 Greenbrier Street Charleston, WV 25311
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0689
F 0689
not been reviewed since 2013 and got us a new one.
Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
MEADOWBROOK ACRES in CHARLESTON, WV inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CHARLESTON, WV, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from MEADOWBROOK ACRES or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.