Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
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 The Meadows during CMS and state inspections, most recent first.
Ice machine contamination was identified when black substance was observed on the underside of the lid and across the interior ledge of the machine used for all residents. The DM confirmed the buildup should have been removed during routine weekly cleaning and acknowledged the machine had not been cleaned properly.
Infection Preventionist Failed to Track and Trend Recurrent UTIs: The designated IP did not complete infection surveillance, track or trend infection data, or analyze recurring UTI patterns. The IP stated she mainly reviewed antibiotic orders and entered them into the monthly log, was unsure of infection criteria, and was behind on documentation. Logs showed multiple recurrent UTIs, including repeated E. coli cultures, but there was no documentation of analysis, source identification, or staff education related to the recurring infections.
Failure to Implement Antibiotic Stewardship and Track UTI Trends: The facility failed to review UTIs using established infection criteria before antibiotics were given and failed to track, trend, or analyze infection data. The IP only logged antibiotic orders, did not review resident symptoms or determine whether infection criteria were met, and was unsure of the UTI criteria. Infection logs showed numerous recurrent UTIs, including a recurring E. coli pattern, but there was no documentation of analysis, source identification, or staff education on prevention measures such as perineal care, catheter care, or hydration.
A facility failed to implement ADL care plan interventions for two residents related to facial hair grooming. Staff observations found chin hairs on both residents, and interviews confirmed CNAs were expected to assess and shave facial hair during bath or shower time. One resident had severe cognitive impairment and required assistance with personal hygiene, while the other had moderate cognitive deficits and required substantial assistance with personal hygiene. The residents’ care plans addressed personal hygiene and ADL support, but staff did not carry out the grooming care as planned.
Two residents who depended on staff for personal hygiene were left with unwanted facial hair despite facility policy stating grooming includes shaving and removal of facial hair. Staff confirmed CNAs were responsible for addressing facial hair during shower time, and both residents were observed with chin hairs; one resident with severe cognitive impairment said she wanted them shaved, and the other said the hair bothered her and made her feel like an odd ball.
Failure to follow infection control precautions involved two residents. One resident on contact isolation for ESBL did not have the required red biohazard barrel in the room, and contaminated PPE was discarded in a regular trash can. Another resident on EBP with a feeding tube had PEG site care performed by an LPN without hand hygiene or the required gown, and the LPN left the room wearing soiled gloves after discarding contaminated gauze on the bedside table.
A resident with atrial fibrillation had an order for Sotalol 120 mg q12h with a facility requirement to check pulse before giving the medication and contact the MD if the pulse was below 60. The pulse was documented below 60 on multiple occasions; one dose was held, but two doses were signed as given without provider notification. The DON and Administrator confirmed the medication should not have been administered without notifying the provider.
A resident with severe cognitive impairment sustained a forehead laceration requiring sutures after a CNA performed a mechanical lift transfer alone, in violation of facility policy and repeated in-service training. The CNA did not request available assistance, resulting in the lift tilting and striking the resident. The incident led to emergency medical intervention and was confirmed by interviews and documentation.
A resident with a suprapubic catheter was observed with an uncovered urinary catheter bag at the bedside, contrary to facility policy requiring privacy covers to maintain dignity. Both an LPN and the DON confirmed that a privacy cover should have been used and that covers were available. The resident had a history of urinary retention and moderate cognitive impairment.
A bed-bound, cognitively intact resident with a history of seizures and subarachnoid hemorrhage was not involved in her care plan meetings, as she was never invited and the care planning team did not accommodate her inability to leave her room. Staff confirmed that the resident and her family were not included in the care planning process, despite facility policy requiring resident participation.
A resident with moderate cognitive impairment and a history of anxiety disorder was not allowed to decide when to get up in the morning, despite expressing a desire to sleep in. Staff required her to get up early based on a predetermined schedule and family wishes, rather than honoring her personal preferences, as confirmed by interviews with the resident, an LPN, and the DON.
A resident with chronic kidney disease, heart failure, and severe cognitive impairment experienced significant weight loss, but the MDS assessment did not accurately document this change as required. The MDS Nurse confirmed the omission, and the DON stated that assessments are expected to reflect the resident's current status.
Ice Machine Not Properly Cleaned
Penalty
Summary
The facility failed to prevent possible contamination of ice used for all residents when an ice machine showed a buildup of a black substance on the inside door and interior ledge during a kitchen tour. Facility policy titled Ice Machine Cleaning Policy required kitchen staff to perform weekly cleanings of ice machines, but observation of the ice machine revealed two areas of black substance, each approximately two to three inches in diameter, on the underside of the ice maker lid, along with black substance covering the interior ledge in small circular spots across the entire surface. The Dietary Manager confirmed the black substance was present, stated the underside of the lid and interior ledge should have been cleaned during routine weekly cleaning, and acknowledged that the ice machine had not been cleaned properly.
Infection Preventionist Failed to Track and Trend Recurrent UTIs
Penalty
Summary
The facility failed to ensure the designated Infection Preventionist (IP) implemented and monitored the Infection Prevention and Control Program by not conducting infection surveillance, tracking and trending infections, analyzing infection data, or identifying infection control concerns. The IP job description stated the IP was responsible for development, implementation, oversight, and evaluation of the program, but the IP reported she only reviewed physician orders for antibiotics and entered information into the monthly infection tracking log. She stated she did not review resident symptoms when monitoring infections, was unsure what infection criteria were used to identify infections, and had not completed the May 2026 infection control log, stating she was usually about one month behind in documentation. Record review of the urinary tracking infection logs from February 2026 through April 2026 identified 54 UTI episodes, excluding residents admitted with infections and duplicate entries for the same active infection, with multiple residents experiencing recurrent UTIs. The logs included resident names, organisms identified, antibiotic treatment, treatment completion dates, and follow-up culture results, but there was no documentation that the infections were analyzed for trends, contributing factors, recurring organisms, or opportunities for intervention. The logs also showed a recurring pattern of E. coli in urine cultures, yet there was no evidence of surveillance to identify contributing factors, determine the source, or implement corrective interventions. The IP confirmed she had not tracked or trended infections, evaluated recurring infection patterns, analyzed infection data, or provided staff education regarding perineal care, catheter care, hydration, or other interventions related to the recurring infections.
Failure to Implement Antibiotic Stewardship and Track UTI Trends
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program and failed to review urinary tract infections using established infection criteria before antibiotic treatment. Based on staff interview, record review, and facility policy review, the infection preventionist only reviewed physician antibiotic orders and entered them into the monthly infection tracking log, without reviewing resident symptoms or determining whether infection criteria were met before treatment. The infection preventionist stated she was unsure what criteria were used to determine whether residents met the requirements for a UTI diagnosis and did not track or trend infections, evaluate recurring infection patterns, or analyze antibiotic utilization. Review of the facility's urinary infection tracking logs from February 2026 through April 2026 identified 54 UTI episodes, excluding residents admitted with infections and duplicate entries for the same active infection. Multiple residents had recurrent UTIs, and the logs showed a recurring pattern of E. coli in urine cultures, but there was no documentation that the facility analyzed the infections, identified contributing factors or the source, or implemented interventions to reduce infections. The May 2026 infection control log was not completed as of 6/2/26, and the infection preventionist stated she was usually about one month behind in documentation. She also stated she was unaware a resident was on contact precautions for ESBL in urine and confirmed she had not provided staff education regarding perineal care, catheter care, hydration, or other measures to reduce UTI occurrence.
ADL Care Plans Not Implemented for Facial Hair Grooming
Penalty
Summary
The facility failed to implement comprehensive ADL care plan interventions for two residents related to facial hair. Facility policy titled Total Care Plan Policy stated that problems affecting residents and their care needs should be identified, interventions related to specific problems should be identified, and the plan should be maintained to the extent practicable. Resident #67’s ADL care plan, dated 11/6/25, directed staff to place personal hygiene items within reach and allow the resident to perform care as able, assisting to complete tasks as needed. However, on 6/1/2026, an observation found several long, curly facial hairs on the resident’s chin. An RN later confirmed the chin hairs were present and stated CNAs should be shaving residents as needed during bath/shower time. The MDS Nurse confirmed the care plan included personal hygiene but was not implemented by staff and stated the care plan was intended to guide staff care. Resident #67’s record showed diagnoses including an unspecified fracture of the upper end of the right tibia, weakness, and vascular dementia, and the MDS dated 4/17/2026 showed a BIMS score of 4 and need for supervision or touching assistance with personal hygiene. Resident #59’s care plan identified limitations in functional abilities/self-care deficit related to generalized weakness with a goal that all ADL needs would be met with staff assistance as required. Observations on 06/01/2026 and 06/03/26 found scattered chin hairs approximately one-half to three-fourths of an inch long. The resident stated staff had not asked about shaving and said it would be good to have a time and place to get it done, adding that the facial hair bothered her and made her feel like an odd ball. A CNA confirmed the resident had facial hair on her chin and stated her scheduled shower days were Mondays, Wednesdays, and Fridays and that the facial hair should have been taken care of. The ADON confirmed CNAs were expected to assess for facial hair on male and female residents during shower time and stated leaving female residents with unwanted facial hair was a dignity issue and not acceptable.
Failure to Provide Grooming and Facial Hair Removal
Penalty
Summary
The facility failed to provide necessary ADL services for two sampled residents who were dependent on staff assistance for personal hygiene and grooming. Facility policy stated that grooming includes shaving and removal of facial hair, and staff interviews confirmed that CNAs were responsible for shaving residents as needed during shower time. Surveyors observed Resident #67 with several long, curly facial hairs on her chin during one observation, and the hairs were still present during a later observation and interview. Resident #67, who had diagnoses including weakness and vascular dementia and a BIMS score of 4 indicating severe cognitive impairment, stated she did not know the hairs were there and said she would like someone to shave them off. Resident #59 was also observed with scattered chin hairs approximately one-half to three-fourths of an inch long. She stated she could not recall staff asking whether she wanted them shaved, said it would be good if staff had a time and place to get it done, and explained that the facial hair bothered her and made her feel like an odd ball. She said she wanted the hair shaved, not plucked. CNA #1, LPN #2, and the ADON all confirmed that facial hair removal should be addressed during shower time and that leaving female residents with unwanted facial hair was a dignity issue. Resident #59 had diagnoses including unspecified dementia, weakness, and hypertensive heart and chronic kidney disease without heart failure, and her BIMS score was 08 with MDS documentation showing substantial/maximal assistance needed for personal hygiene.
Failure to Follow Infection Control Precautions
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program by not following Enhanced Barrier Precautions for Resident #91 and by not providing an appropriate biohazard container for Resident #118, who was on transmission-based precautions. The facility policy stated that red/yellow bagged barrels would be used for contact isolation. Resident #118 had a physician order for contact isolation precautions related to ESBL in urine, but during observation the resident’s room did not have a red bag/biohazard barrel for contaminated waste and PPE, and gowns, gloves, and masks were discarded in a regular trash can in the bathroom. RN #1 stated there should have been a barrel in the room, and the IP stated there should have been a red barrel in the room and that she was not aware the resident was on contact precautions. For Resident #91, signage for Enhanced Barrier Precautions was posted outside the room, and the resident had diagnoses including dysphagia following cerebral infarction and encounter for attention to gastrostomy, with an MDS showing a feeding tube. During PEG tube site care, the LPN did not perform hand hygiene and did not don the required gown before starting care. The LPN also discarded a soiled gauze pad onto the bedside table, left it there, and exited the room wearing the same soiled gloves used during care. The LPN acknowledged the error and stated that gown and glove use was required for the resident’s PEG site care, and the IP and ADON confirmed that gown and glove use, hand hygiene, and removal of soiled gloves before leaving the room were expected infection control practices.
Failure to Notify Provider Before Administering Pulse-Dependent Medication
Penalty
Summary
The facility failed to notify the medical provider before administering Sotalol to a resident when the resident’s pulse rate was below the facility’s required threshold of 60. The resident was admitted with a diagnosis of atrial fibrillation and had a physician’s order for Sotalol 120 mg every 12 hours. Facility documentation stated that medications requiring pulse monitoring should be checked by radial pulse for one full minute before administration, and if the pulse is below 60, the physician should be contacted for guidance prior to giving the medication. Review of the resident’s November 2025 medication record showed that the pulse rate dropped below 60 on three occasions. On one occasion, the medication was held when the pulse was 50, but on two other occasions the pulse was 56 and 55, and Sotalol was signed as administered without physician notification. The DON confirmed that the medication should not have been administered when the pulse was below 60 and stated that no documentation could be found showing the provider was notified. The Administrator also confirmed that nursing staff should have notified the provider when the pulse rate dropped below 60 for further instruction.
Resident Injury Due to Improper Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident using a mechanical lift without the required assistance of a second staff member, contrary to facility policy and manufacturer guidelines. The CNA admitted to performing the transfer alone and not positioning the lift legs properly, which caused the lift to tilt and the bar to strike the resident's forehead. The CNA acknowledged being aware of the policy requiring two staff for lift transfers and had received multiple in-services on lift safety, but chose not to request help even though other staff were available. The incident resulted in the resident sustaining a significant laceration to the forehead, which required emergency medical evaluation and sutures. At the time of the incident, the resident was noted to have severe cognitive impairment due to Alzheimer's Disease and was unable to participate in her own care decisions. The resident was found by a registered nurse (RN) still attached to the lift, with active bleeding from the forehead, and was subsequently sent to the emergency room for further assessment and treatment, including a CT scan and pain management. Facility records confirmed that the CNA had attended multiple in-services on lift safety and had signed off on training related to the use of mechanical lifts and slings. Interviews with the RN, Director of Nursing (DON), and Administrator all confirmed that the facility's policy requires two staff members for mechanical lift transfers and that this policy was not followed, directly resulting in the resident's injury.
Failure to Provide Privacy Cover for Catheter Bag
Penalty
Summary
Staff failed to ensure the use of a privacy cover for a urinary catheter bag for one resident with a suprapubic catheter. Facility policy required catheter bags to be placed inside a privacy bag to maintain resident dignity. During observation, the resident was found lying in bed with the catheter bag hanging at the bedside, uncovered and lacking a privacy cover. Both the LPN and the Director of Nursing confirmed that a privacy cover should have been used, and that sufficient covers were available in the facility. The resident involved had a history of urinary retention and had an order for an indwelling suprapubic catheter. The Minimum Data Set assessment indicated the resident had moderately impaired cognitive status. Facility policies on catheter placement and dignity emphasized the importance of providing care in a manner that maintains or enhances each resident's dignity, which was not followed in this instance.
Failure to Involve Bed-Bound Resident in Care Plan Development
Penalty
Summary
The facility failed to involve a bed-bound resident in the development and implementation of her person-centered care plan. Despite facility policy requiring that residents and/or their responsible parties be invited to care plan conferences at least one week in advance, the resident reported never being invited to such meetings. She stated that she was bed-bound, did not leave her room, and had not been informed about care plan meetings. The resident also confirmed that her family was not involved in her care. Staff interviews revealed that while care plan meetings were held weekly, the team did not make accommodations to include the resident by holding the meeting in her room, despite her cognitive intactness as indicated by a BIMS score of 15. Social Services staff acknowledged that the resident preferred not to leave her room and confirmed that the care planning team did not attempt to involve her directly in the meetings. The DON also confirmed that the resident should have been involved in care plan meetings and should have had a direct voice in her care. The resident had been admitted with medical diagnoses including seizures and sequelae of nontraumatic subarachnoid hemorrhage, and was observed to be bed-bound at the time of the deficiency.
Resident's Right to Self-Determination Not Honored
Penalty
Summary
A deficiency occurred when a resident was not allowed to exercise her right to make important care-related decisions, specifically regarding her preferred time to get up in the morning. The resident, who was moderately cognitively impaired and diagnosed with Mixed Anxiety Disorder, expressed on multiple occasions that she did not want to get up early and preferred to sleep in. Despite her requests, staff required her to get up early, citing her daughter's wishes for her to be up for all meals. The resident reported feeling that her preferences were not honored, and this was confirmed during interviews with both the resident and staff. Staff interviews revealed that the resident was on a predetermined list to be awakened early by the night shift, which began getting residents up around 5:30 AM. The LPN acknowledged that the resident had voiced her desire to sleep in and recognized that it was the resident's right to make such care choices. The Director of Nursing also confirmed that the resident should be able to make decisions about her care, such as choosing when to get up. Facility policy review supported the resident's right to exercise self-determination, but this right was not upheld in this instance.
Failure to Accurately Complete MDS for Resident with Significant Weight Loss
Penalty
Summary
The facility failed to accurately complete Section K of the Minimum Data Set (MDS) for a resident who experienced significant weight loss. Specifically, the resident's weight dropped from 230.3 pounds to 206.6 pounds between two documented dates, representing a 10.29% loss. However, the 5-day MDS assessment did not indicate a weight loss of 5% or more in the last month as required. This omission was confirmed by the MDS Nurse, who acknowledged that the weight loss should have been captured but was missed. The resident involved had a history of chronic kidney disease stage 3 and chronic systolic congestive heart failure and was severely cognitively impaired, as indicated by a Brief Interview for Mental Status (BIMS) score of 3. The DON stated that her expectation was for MDS staff to accurately reflect the resident's status at the time of assessment. The facility's policy requires that the Resident Assessment Instrument (RAI) be completed according to CMS guidelines, but this was not followed in this instance.
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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.
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Nursing homes near Fulton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Courtyards Comm Living Center | 2 mi | ★★★★★ | 0 | 0 |
| Diversicare Of Tupelo | 15.5 mi | ★★★★★ | 11 | 0 |
| Tupelo Community Care Center | 15.8 mi | ★★★★★ | 9 | 0 |
| River Place Nursing Center | 18.3 mi | ★★★★★ | 6 | 0 |
| Diversicare Of Amory | 18.5 mi | ★★★★★ | 11 | 0 |
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