The Meadows

In the surveyor’s words

From the most serious findings on record at The Meadows, in the surveyor’s own words.

• Immediate jeopardy, isolatedF695Aug 12, 2022

  Based on observation, staff interview, facility policy review, Mississippi (MS) State Board of Nursing website review, and the Nurse Practice Act, the facility failed to ensure a Registered Nurse (RN) and/or Respiratory Therapist (RT) were scheduled for each shift to provide consistent respiratory care services, 24 hours each day to deep suction the [CONDITION(S)] ([CONDITION(S)]), if needed and /or provide other emergency care related to the [CONDITION(S)], to a resident with a [CONDITION(S)], for one (1) of 1 resident reviewed with a [CONDITION(S)], Resident #26. During a review of the facility Staffing Grid, the facility did not have RN or RT coverage for the 11-7 shift on 08/05/2022 and there was not an RN assigned on the 3-11 shift and the 11-7 shift on 08/06/2022. […]

• Actual harm, isolatedF689Nov 3, 2025

  Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure the safety of a resident during a mechanical lift transfer and a resident sustained a forehead laceration requiring sutures for one (1) of four (4) residents sampled. Resident #1Findings include:Record review of facility policy titled, Total Lift Policy with revision date of 2/2/17 revealed, It is the policy of the facility that a total lift will be utilized as follows: by a licensed nurse or CNA (Certified Nursing Assistant) . It requires two employees when lift is used .A phone interview with CNA #1 on 11/3/25 at 10:40 AM, revealed she was the CNA caring for Resident #1 when the lift incident occurred. […]

• No harm, potential for more than minimal, widespreadF812Jun 4, 2026

  Based on observation, staff interview, and facility policy review, the facility failed to prevent the possible contamination of ice, as evidenced by a buildup of a black substance on the inside door and the interior ledge of the ice machine that was used for all residents for one (1) of three (3) kitchen 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. […]

• No harm, potential for more than minimal, widespreadF882Jun 4, 2026

  Based on record review, staff interview, and facility policy review, the facility failed to ensure the designated Infection Preventionist implemented and monitored the facility's Infection Prevention and Control Program by failing to conduct infection surveillance, track and trend infections, analyze 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). […]

• No harm, potential for more than minimal, patternF881Jun 4, 2026

  Based on staff interview, record review, and facility policy review, the facility failed to implement an effective antibiotic stewardship program, failed to ensure urinary tract infections (UTIs) were reviewed using established infection criteria before antibiotic treatment, failed to track and trend infection data, and failed to identify and implement interventions to reduce infections for numerous UTI episodes identified on the facility's infection tracking logs from February 2026 through April 2026.This was for three (3) of four (4) months reviewed.Findings include:Review of the facility policy titled Antibiotic Stewardship Policy revealed, It is the policy of this facility to minimize inappropriate and unnecessary antibiotic use and improve patient outcomes. […]