Meadowbrook Acres
MEADOWBROOK ACRES in CHARLESTON, WV — inspection on November 6, 2025.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/06/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Meadowbrook Acres
2149 Greenbrier Street Charleston, WV 25311
SUMMARY STATEMENT OF DEFICIENCIES
since.
The DON further stated, I noticed our policy had not been reviewed since 2013 and got us a new one.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/06/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Meadowbrook Acres
2149 Greenbrier Street Charleston, WV 25311
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/06/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Meadowbrook Acres
2149 Greenbrier Street Charleston, WV 25311
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/06/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Meadowbrook Acres
2149 Greenbrier Street Charleston, WV 25311
SUMMARY STATEMENT OF DEFICIENCIES
not been reviewed since 2013 and got us a new one.
Facility ID: