The Meadows
THE MEADOWS in FULTON, MS — inspection on June 4, 2026.
Found 6 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
Resident #59 with scattered chin hairs that were approximately one-half to three-fourths of an inch in
bothered her to have facial hair and stated, It makes me feel like an odd ball.
On 06/03/26 at 9:55 AM, during an interview and observation with Certified Nursing Assistant (CNA) #1, she confirmed that Resident #59 had facial hair to her chin. CNA #1 revealed that Resident #59's scheduled shower days were Mondays, Wednesdays, and Fridays and confirmed that her facial hair should have been taken care of.
An interview on 06/03/26 at 10:05 AM with Assistant Director of Nursing (ADON), revealed that she wanted the residents to look nice, look presentable, and to feel good about themselves. ADON revealed that they expected their CNAs to assess for facial hair on male and female residents during their shower time.
She confirmed that Activities of Daily Living (ADL) Care was including on the Care Plan and should have been completed.
She also revealed that leaving female residents with unwanted facial hair was a dignity issue and was not acceptable.
Record review of Resident #59's Record of admission form revealed an admission date of 01/20/25 and that she had diagnoses that included Unspecified Dementia, Weakness, and Hypertensive Heart and Chronic Kidney Disease without Heart Failure.
Record review of Resident #59's Brief Interview for Mental Status (BIMS) Assessment completed on 03/20/26 revealed a score of 08 which indicated that she had moderate cognitive deficits.
Record review of Resident #59's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 04/12/26 under Section GG revealed that she required substantial/maximal assistance with her personal hygiene.
255160 06/04/2026
The Meadows 1905 South Adams Street Fulton, MS 38843
During an observation and interview on 06/03/26 at 9:55 AM with Certified Nursing Assistant (CNA)
scheduled shower days were Mondays, Wednesdays, and Fridays and confirmed that removal of facial hair was the CNAs responsibility to take care of during that time.
She stated, I don't like to have body hair myself and revealed she would take care of it.
During an observation and interview on 06/03/26 at 10:00 AM with Licensed Practical Nurse (LPN) #2, she confirmed that Resident #59 had facial hair to her chin.
She stated, I wouldn't like to have facial hair, it would bother me too.
She also revealed that facial hair should be addressed during resident showers.
An interview on 06/03/26 at 10:05 AM with Assistant Director of Nursing (ADON), revealed that she wanted the residents to look nice, look presentable, and to feel good about themselves. ADON revealed that they expected their CNAs to assess for facial hair on male and female residents during their shower time.
She also confirmed that leaving female residents with unwanted facial hair was a dignity issue and was not acceptable.
Record review of Resident #59's Record of admission form revealed an admission date of 01/20/25 and that she had diagnoses that included Unspecified Dementia, Weakness, and Hypertensive Heart and Chronic Kidney Disease without Heart Failure.
Record review of Resident #59's Brief Interview for Mental Status (BIMS) Assessment completed on 03/20/26 revealed a score of 08 which indicated that she had moderate cognitive deficits.
Record review of Resident #59's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 04/12/26 under Section GG revealed that she required substantial/maximal assistance with her personal hygiene.
255160 06/04/2026
The Meadows 1905 South Adams Street Fulton, MS 38843
serve food in accordance with professional standards.
possible contamination of ice, as evidenced by a buildup of a black substance on the inside door and
tours.Findings Include:
Record review of the facility policy titled Ice Machine Cleaning Policy with an effective date of 5/3/2021 revealed, .The kitchen staff will be responsible for weekly cleanings of ice machines in the kitchen .During the initial kitchen tour on 6/1/2026 at 10:24 AM, 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.
Black substance was also observed along the interior ledge of the ice machine.
The interior ledge was covered with small, circular spots of the black substance that extended across the entire ledge surface.
During an interview on 6/1/2026 at 10:25 AM, the Dietary Manager (DM) confirmed the presence of the black substance observed on the underside of the ice maker lid and on the interior ledge of the ice machine.
The DM stated that dietary staff clean the ice machine weekly and that the underside of the lid and the interior ledge should have been cleaned during the routine cleaning process.
The DM acknowledged that the black substance should not have been present and that its presence showed the ice machine had not been cleaned properly.
The DM also stated that the black substance could potentially cause illness in residents and staff.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
255160 06/04/2026
The Meadows 1905 South Adams Street Fulton, MS 38843
During the treatment, LPN #1 cleansed the PEG site and discarded a soiled gauze pad onto the bedside table. LPN #1 immediately stated, Oh, I shouldn't have done that, however, the soiled gauze remained on the bedside table.
Upon completion of the treatment, LPN #1 bagged the trash and exited the resident's room to dispose of it while continuing to wear the same soiled gloves.
During an interview on 6/02/2026 at 2:10 PM, LPN #1 confirmed Resident #91 was on Enhanced Barrier Precautions and stated, We usually just use gloves when we do his PEG site care. I think we wear gowns and gloves when they have a wound.
After reading the Enhanced Barrier Precautions signage posted outside the resident's room, LPN #1 stated, I guess I screwed up.
According to the sign, we are supposed to wear a gown since he has a PEG tube. LPN #1 further acknowledged that wearing the same soiled gloves from the resident's room into the hallway was an infection-control concern and that the gloves should have been removed and discarded before exiting the room.
During an interview on 6/02/2026 at 2:40 PM, the Infection Preventionist confirmed that Enhanced Barrier Precautions are required when providing PEG site care and explained that these precautions are intended to reduce the risk of transmission of infectious organisms.
During an interview on 6/03/2026 at 4:05 PM, the Assistant Director of Nursing (ADON) revealed it is the facility's expectation that infection control practices are consistently followed to prevent the spread of infection.
The ADON confirmed staff are trained to wear the appropriate personal protective equipment (PPE), including both a gown and gloves, when providing care to residents on Enhanced Barrier Precautions.
The ADON further stated that proper hand hygiene and removal and disposal of soiled gloves before leaving the resident's room are expected infection control practices.
Record review of the Record of Admission revealed Resident #91 was admitted to the facility on [DATE] Record review of the Client Diagnosis Report revealed Resident #91 has diagnoses which include Dysphagia following cerebral infarction, and Encounter for attention to gastrostomy.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/3/26 revealed under Section K. that Resident #91 had a Feeding tube.
stated the recurring infections should have been analyzed to identify the cause and implement
255160 06/04/2026
The Meadows 1905 South Adams Street Fulton, MS 38843
program in the nursing home.
designated Infection Preventionist implemented and monitored the facility's Infection Prevention and
infection data and identify infection control concerns.
This deficient practice had the potential to affect all 118 residents residing in the facility.Findings Include:
Record review of the facility policy titled Compliant Infection Preventionist (IP) Job Description revealed under, Position Summary: The Infection Preventionist (IP) is responsible for the development, implementation, oversight, and evaluation of the facility's Infection Prevention and Control Program (IPCP).
The IP works collaboratively with nursing, medical staff, department managers, residents, families, and community agencies to prevent, identify, investigate, monitor, and control infections and communicable diseases throughout the facility .
Record review of the facility's Urinary Tracking Infection Logs from February 2026 through April 2026 identified 54 urinary tract infection (UTI) episodes, excluding residents admitted with infections and duplicate entries for the same active infection.
Multiple residents experienced recurrent UTIs.
The infection tracking logs included resident names, organisms identified, antibiotic treatment, treatment completion dates, and follow-up culture results.
However, there was no documentation demonstrating the infections were analyzed for trends, contributing factors, recurring organisms, or opportunities for intervention.
Record review revealed the May 2026 infection control log had not been completed as of 6/2/26.
Record review of Resident #118's physician orders revealed an order dated 6/2/26 for Contact Precautions for ESBL (Extended-Spectrum Beta-Lactamase) in urine every shift.On 6/3/26 at 2:30 PM, during an interview with the Infection Preventionist (IP), she stated she had not completed the May 2026 infection control log and usually remained approximately one month behind in infection control documentation.
The IP stated she was unaware a resident was currently on contact precautions for an infection and could not identify the type of infection.
She stated floor nurses were responsible for implementing precautions and ensuring the required equipment was available in the resident's room.On 6/3/26 at 10:00 AM, during an interview with the IP, she stated she had served in the role since 2018 and dedicated approximately three days per week to infection prevention activities.
The IP stated she was unsure what infection criteria were used to identify infections and would need to review the facility policy.
The IP stated she did not review resident symptoms when monitoring infections.
The IP stated she only reviewed physician orders for antibiotics and entered the information into the monthly infection tracking log.
The IP confirmed she did not track or trend infections, evaluate recurring infection patterns, or analyze infection data.
The IP stated UTIs had been a recurring concern within the facility.
The IP further confirmed she had not provided staff education regarding perineal care, catheter care, hydration, or other interventions to address the recurring infections.On 6/3/26 at 10:38 AM, during an interview with the Administrator after reviewing the infection tracking logs, confirmed the infection tracking process was lacking.
Record review of the facility's Urinary Tracking Infection Logs from February 2026 through April 2026 identified a recurring pattern of urinary tract infections caused by Escherichia coli (E. coli).
Despite the recurring trend, there was no evidence the facility conducted surveillance activities to identify contributing factors, determine the source, or implement corrective interventions.An interview on 6/3/26 at 3:45 PM, with the Assistant Director of Nursing (ADON) revealed the IP should identify infection sources, track infection patterns, and ensure interventions were implemented to address identified concerns.
The ADON confirmed there was no tracking or trending of infection data.
After reviewing the infection logs, the ADON identified a recurring concern involving E. coli in urine cultures and stated staff education regarding perineal care, catheter care, hydration, and other prevention measures should have been conducted.
The ADON stated the recurring infections should have been analyzed to identify the cause and implement corrective actions.
255160 06/04/2026
The Meadows 1905 South Adams Street Fulton, MS 38843
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.