Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Meadowbrook Acres during CMS and state inspections, most recent first.
Three residents with care plans or orders for bed rails to assist with mobility, transfers, or repositioning were observed without the required side rails in place. The DON confirmed that the bed rails were not present as specified in the care plans or orders.
Surveyors found that staff did not follow physician orders for side rail use and failed to perform required neurological checks after unwitnessed falls. Multiple residents who had orders for side rails to assist with mobility and repositioning were observed without them in place, and a resident with a history of falls did not receive neuro checks as per facility policy. The DON confirmed these omissions during interviews.
A registered nurse administered medication to a resident during a Bible Study activity, entering a closed room marked for the event. The nurse indicated this practice occurs even when not behind schedule, and an activity assistant confirmed medications are often given during activities. This action did not comply with the facility's policy requiring privacy during medication administration.
A resident with a known history of wandering and multiple exit-seeking incidents was able to elope from the facility several times over nine months, including one event where the resident was found at a local ER. Despite being identified as high risk and wearing a wander guard bracelet, the care plan interventions were not updated to include increased supervision or monitoring, and staff failed to ensure facility doors were properly secured, directly contributing to the resident's ability to leave the premises.
A resident with a known history of exit-seeking behavior and multiple successful elopements was able to leave the facility after staff failed to ensure a door was properly latched. Despite risk assessments and a wander guard bracelet, the resident's care plan and supervision were insufficient to prevent repeated elopement attempts, and documentation of discussions about higher-level interventions was lacking.
A janitor's closet containing hazardous chemicals and a medication cart were both found unlocked and unattended. Additionally, a resident was observed using a vape inside the building before reaching the designated supervised smoking area, contrary to facility policy and the resident's care plan. Staff confirmed these lapses in supervision and safety procedures.
Surveyors found that the facility did not consistently complete required narcotic medication logbook reconciliations at shift changes in two halls. Multiple entries and nurse signatures were missing for various shifts, and these documentation lapses were confirmed by the Administrator during the survey.
A rack of plate lids was found stored against an open utility-room door in the kitchen, where dirty mops, rags, and chemicals were present. The Dietary Manager acknowledged this was not an appropriate storage location, potentially affecting all residents receiving meals from the kitchen.
A resident was left without a meal while seated with others who were eating, as staff served seven additional tables before the issue was noticed and addressed. The DON confirmed the resident should have been served alongside their tablemates, indicating a lapse in ensuring dignity and respect during meal service.
A resident was started on Zoloft (Sertraline HCI) for anxiety disorder without a signed consent form in the medical record. The DON confirmed that consent was not obtained prior to initiating the psychotropic medication.
A resident was discharged home after the last covered day of Medicare Part A services, but the required Notice of Medicare Non-Coverage (NOMNC) was provided only 24 hours in advance instead of the mandated 48 hours. This was confirmed by the BOM during a review of beneficiary protection notifications.
A resident with dementia, blindness, and limited mobility experienced two incidents where nurse aides failed to use a required Hoyer lift during transfers, resulting in injury and pain. Although facility policy required all nurse aides to be re-educated after such events, only the aides directly involved received training, and the administrator confirmed that the rest of the staff did not receive the mandated re-education.
A resident dependent on staff for ADL care was found covered in dried feces, with both the resident and bed soiled due to lack of timely hygiene assistance. Staff statements and interviews confirmed the failure to provide necessary care, and the incident was reported as neglect to authorities.
A resident's monthly pharmacy reviews for two months were not signed by the facility physician, and there was no documentation to show whether the physician agreed or disagreed with the pharmacy's recommendations. The administrator confirmed the absence of physician signatures on these reviews.
A resident was prescribed Zoloft 50mg daily for anxiety disorder without a signed consent form in the medical record. The DON confirmed the absence of the required consent documentation for this psychotropic medication.
A resident was found to have two medications—Eye Scrubs External Pad and Metoprolol Tartrate—documented in their medical record without corresponding diagnoses. This lack of documentation was confirmed by the Administrator and DON during the survey.
The facility failed to implement comprehensive care plans for two residents with behavioral issues. One resident was involved in an incident of inappropriate touching, while another punched a fellow resident. Despite these incidents, their care plans lacked behavioral focus, goals, or interventions. The administrator acknowledged these deficiencies.
Failure to Implement Bed Rail Care Plan Interventions
Penalty
Summary
The facility failed to develop and implement care plans for the application of bed rails for three residents who had physician orders or care plan interventions specifying the use of side rails for assistance with bed mobility, transfers, or repositioning. For one resident, current orders indicated the use of bilateral upper side rails to assist with bed mobility and transfers, and the care plan included this intervention; however, observation revealed that no side rails were present on the bed. This finding was confirmed by the Director of Nursing (DON). Similarly, another resident had a fall care plan intervention for half bilateral side rails to the head of the bed to increase independence with positioning and personal care, but observation showed the resident lying in bed without the side rails in place as specified in the care plan. The DON confirmed the absence of side rails. A third resident had a care plan order for bilateral quarter side rails to assist with repositioning and bed mobility, but observation again revealed no side rails in place, which was acknowledged by the DON. These findings demonstrate that the facility did not implement the care plan interventions related to bed rail use as ordered for these residents.
Failure to Follow Physician Orders for Side Rails and Neurological Checks
Penalty
Summary
The facility failed to provide care in accordance with professional standards by not following physician orders for side rail implementation and neurological checks for four residents reviewed for fall interventions. Specifically, several residents had physician or care plan orders for bilateral or quarter side rails to assist with bed mobility and repositioning, but observations revealed that these side rails were not in place as ordered. The Director of Nursing confirmed in each case that the side rails were missing despite the documented orders and care plans. Additionally, a resident who experienced an unwitnessed fall did not receive neurological assessments as required by the facility's policy, which mandates a specific schedule of neuro checks following such incidents. The Director of Nursing acknowledged that these assessments were not performed for the resident after the unwitnessed fall, despite the policy and the resident's history of multiple falls. These findings were based on record reviews, staff interviews, and direct observations during the survey process.
Medication Administration During Activity Lacks Privacy and Dignity
Penalty
Summary
A deficiency was identified when a registered nurse entered a closed recreation room during a Bible Study activity and administered medication to a resident. The door to the room was marked with a sign indicating that Bible Study was in progress. The nurse stated that medications are sometimes given during activities or in the dining room, not due to being behind schedule but to expedite the process. An activity assistant confirmed that medications are routinely administered during activities. Review of the facility's medication administration policy revealed a requirement to provide privacy during medication administration, which was not followed in this instance.
Failure to Prevent Repeated Elopements Due to Inadequate Supervision and Monitoring
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent repeated elopements for a resident identified as being at risk for wandering and exit-seeking behaviors. Over a nine-month period, the resident exhibited more than 20 instances of exit-seeking or attempted elopement, with five successful elopements, including one incident where the resident was found at a local emergency room after leaving the facility. Documentation showed that the resident had a history of wandering, was assessed as high risk for elopement, and wore a wander guard bracelet since admission. Despite these risk factors and repeated incidents, the care plan interventions remained unchanged and did not include increased supervision or more frequent monitoring. Staff interviews and record reviews revealed that on the day of the most recent elopement, three evening shift staff members failed to ensure that a facility door was properly latched, which allowed the resident to leave undetected for approximately two hours. The facility's elopement policy in place at the time had not been updated since 2013, and interventions in the care plan were limited to distraction techniques and routine checks of the wander guard device, without escalation in response to the resident's ongoing behaviors. There was also a lack of documentation regarding discussions with the resident's family about potential placement in a more secure unit.
Failure to Prevent Repeated Elopements Due to Inadequate Supervision and Monitoring
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent repeated elopements for a resident identified as being at risk. Record review showed that the resident had a history of exit-seeking behavior, with documentation of at least 20 incidents of attempting to leave the facility and five successful elopements over a period of several months. Despite being assessed as at risk for elopement and having a wander guard bracelet in place, the resident was able to leave the facility when staff failed to ensure a door was properly latched. The resident was later found at a local emergency room after being missing for approximately two hours. The care plan for the resident included interventions such as involving the resident in activities, providing diversions, and ensuring the wander guard bracelet was worn and checked, but these measures were not sufficient to prevent repeated elopement attempts. Staff interviews revealed that discussions about moving the resident to a locked unit were not documented, and the DON acknowledged that more frequent monitoring, such as one-on-one supervision or 15-minute checks, was not implemented. The facility's elopement policy in place at the time had not been updated since 2013.
Failure to Prevent Accident Hazards and Inadequate Supervision
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards and did not provide adequate supervision to prevent accidents. Observations revealed that a janitor's closet on the B hall was repeatedly found unlocked and unattended, containing various cleaning chemicals such as Clorox Clean-up, Sani-Clean 2 spray, and bleach germicidal wipes. The Maintenance Assistant confirmed that the closet should always be locked but stated the lock was broken and was unsure how long it had been in that condition. Additionally, a medication cart on the B Hall was observed unlocked and unattended, and an LPN confirmed that the cart should not be left in this state. A resident who was permitted to smoke a vape (electronic cigarette) only at designated times and in a designated outdoor area with staff supervision was observed using the vape inside the building before reaching the designated area. The resident's care plan and facility policy required the vape to be used only under supervision and in the specified location, with the device stored in the medication cart and charged by nursing staff. The staff member accompanying the resident acknowledged that the resident was not supposed to use the vape before exiting the building, and the Administrator confirmed this expectation.
Failure to Properly Reconcile Narcotic Medication Logbooks at Shift Changes
Penalty
Summary
The facility failed to ensure proper reconciliation of the narcotic medication logbook for both A Hall and B Hall, as observed during the medication administration process. On multiple occasions between 02/18/25 and 04/09/25, required entries and nurse signatures were missing for various shift changes. Specific deficiencies included the absence of entries for entire shifts and missing nurse signatures for both coming on and going off duty. These lapses were confirmed by the Administrator, who acknowledged that the reconciliation process was not completed as required on the identified dates. The findings were based on direct observation, record review, and staff interviews. The narcotic medication logbooks for both halls showed repeated failures to document the transfer and accountability of controlled substances at shift changes, as required by facility policy and regulatory standards. No information was provided regarding specific residents affected or their medical conditions at the time of the deficiency.
Improper Storage of Plate Lids Near Utility Room
Penalty
Summary
Surveyors observed that a rack of plate lids was stored directly against an open utility-room door in the kitchen. The utility room contained a mop sink, dirty mops, rags, and chemicals. This storage practice did not align with professional standards for food service safety. During an interview, the Dietary Manager acknowledged that the plate lids should probably not be stored in that location with the door open. This deficiency had the potential to affect all residents who received their nutrition from the kitchen, as improper storage of food service items was observed.
Resident Not Served Meal with Tablemates During Lunch Service
Penalty
Summary
During a meal service observation, a resident was seated at a table with two other residents and a visitor who were all eating lunch, while the resident watched without being served their meal. The surveyor noted that seven additional tables were served before intervening. The Director of Nursing confirmed that the resident should have been served at the same time as the others at the table. This incident demonstrated a failure to treat the resident with respect and dignity during meal service, as the resident was left waiting while others around them ate.
Failure to Obtain Consent for Psychotropic Medication
Penalty
Summary
Facility staff failed to ensure that a resident and/or their medical representative was informed of and participated in the decision to initiate a psychotropic medication. Specifically, a physician order was present for Zoloft (Sertraline HCI) 50 mg daily for the treatment of anxiety disorder for one resident. Upon review of the medical record, there was no signed consent form for the administration of Zoloft. The Director of Nursing confirmed during an interview that no such consent form existed for this resident.
Failure to Provide Timely Medicare Non-Coverage Notification
Penalty
Summary
The facility failed to provide timely notification of Medicare non-coverage to a resident who was discharged home following the last covered day of Medicare Part A services. Specifically, the Notice of Medicare Non-Coverage (NOMNC) was issued only 24 hours prior to the end of covered services, rather than the required minimum of 48 hours as outlined in the CMS-10123 form instructions. This deficiency was identified during a review of records and confirmed by the Business Office Manager, who acknowledged that the notification was not provided within the mandated timeframe. The review focused on one of three residents sampled for beneficiary protection notification, with the facility census at 54 residents at the time of the survey.
Failure to Re-Educate All Nurse Aides After Substantiated Neglect
Penalty
Summary
The facility failed to implement its policy regarding the re-education of all nurse aide (NA) staff following substantiated allegations of neglect involving a resident with dementia, blindness, limited functional mobility, and generalized muscle weakness. In two separate incidents, nurse aides did not follow the resident's care plan, which required two-person assistance and the use of a full body Hoyer lift for transfers. In both cases, the aides involved did not use the lift, resulting in a skin tear in one incident and pain in the resident's leg in another. Although the facility's policy required that all NAs be re-educated after such incidents, documentation showed that only the directly involved aides received re-education. There was no evidence that the rest of the NA staff received the required training. The administrator confirmed that not all NAs were re-educated as stipulated by the facility's policy.
Failure to Provide Timely ADL Care Resulting in Resident Neglect
Penalty
Summary
A resident who was dependent on staff for activities of daily living (ADLs) was found covered in dried feces from head to toe, as reported by her son and confirmed by both a nurse aide and a registered nurse. The incident occurred on 11/17/24, and documentation showed that the resident and her bed were soiled with dried feces, indicating a lack of timely ADL care. The facility's records confirmed that the resident did not receive necessary assistance with hygiene and care according to her assessed needs, resulting in the incident being reported to state and local authorities for neglect. The deficiency was substantiated through staff statements and interviews, including confirmation from the Director of Nursing that the resident did not receive timely care.
Physician Review of Pharmacy Recommendations Not Documented
Penalty
Summary
The facility failed to ensure that two monthly pharmacy reviews for one resident were reviewed and signed by the facility physician. Specifically, a record review for one resident revealed that the pharmacy reviews for two separate months were not signed by the physician, and there was no documentation indicating whether the physician agreed or disagreed with the pharmacy's recommendations. This deficiency was confirmed by the facility administrator, who acknowledged that neither of the pharmacy reviews had been signed by the physician as required.
Lack of Consent for Psychotropic Medication
Penalty
Summary
A deficiency was identified when a review of the medical record for one resident revealed a physician's order for Zoloft (Sertraline HCI) 50mg daily for anxiety disorder, but there was no signed consent form for this psychotropic medication in the resident's file. This omission was confirmed during an interview with the Director of Nursing, who acknowledged that the required consent form for Zoloft was not present for the resident. The lack of a signed consent form indicated that the facility failed to ensure the resident's drug regimen was free from unnecessary medications, as required documentation was missing.
Incomplete Medical Records for Medications
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one resident, as identified during a record review. Specifically, two medications prescribed to the resident—Eye Scrubs External Pad and Metoprolol Tartrate 25mg—were found to lack associated diagnoses in the resident's medical record. This omission was confirmed by both the Administrator and the DON during the survey. The deficiency was identified during a review of residents under the care area of unnecessary medications, with the facility census at 57 residents at the time.
Failure to Implement Behavioral Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives for residents exhibiting behavioral issues. This deficiency was identified for two residents. Resident #43 was involved in an incident where he was reported to have been touching another resident, leading to the other resident biting him. Despite this incident, the care plan for Resident #43, which was initiated in December 2022 and revised in January 2023, did not include any behavioral focus, goals, or interventions following the incident in April 2024. The facility administrator acknowledged that the care plans did not reflect appropriate behavioral interventions. Similarly, Resident #6 was involved in an incident where she punched another resident, claiming they were thieves. This incident occurred in April 2024, but the care plan for Resident #6, initiated in August 2022 and revised in February 2024, also lacked any behavioral focus, goals, or interventions following the incident. The administrator again acknowledged the deficiency in the care plans, which failed to address the residents' behavioral needs adequately.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 114 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Charleston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Oak Ridge Llc | 2.9 mi | ★★★★★ | 0 | 0 |
| Arthur B Hodges Center, The | 3.9 mi | ★★★★★ | 0 | 0 |
| Charleston Healthcare Center | 4 mi | ★★★★★ | 14 | 0 |
| Thomas Hospitals Skilled Nursing Unit | 4.1 mi | ★★★★★ | 0 | 0 |
| Dunbar Center | 8.2 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.