Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Ruleville Community Care Center during CMS and state inspections, most recent first.
A resident with chronic pain, neuropathy, and a cervical spinal cord injury did not receive fentanyl patches as ordered on multiple occasions. The resident reported repeated missed doses by a 3-11 shift nurse, and MAR and controlled drug record review confirmed missed administrations. RN and DON interviews acknowledged the orders were not followed, and the resident’s pain scores increased during the missed or delayed dosing periods.
Failure to Follow Care Plans for Hygiene and Pain Management: Staff did not follow care plans for several residents who depended on assistance with nail care and bathing, and one resident’s pain regimen was not carried out as ordered. Residents were observed with long or unclean fingernails, greasy hair, and body odor, while an LPN, CNA, RN, and the ADM confirmed the findings. A resident with chronic pain also missed ordered fentanyl patch doses, and the MDS nurse confirmed the pain care plan was not followed.
A facility failed to provide basic hygiene care for dependent residents by missing scheduled showers and routine nail care. Several residents were observed with greasy hair, body odor, or long fingernails with brown debris, and staff confirmed the findings. Residents with diabetes, hemiplegia, and other diagnoses reported not receiving showers as scheduled, while staff stated nail care should be completed during bath/shower times and that long, dirty nails could cause infection or scratching.
A resident reported pain caused by a CNA during repositioning and filed a grievance, but there was no follow-up or documentation showing the grievance was resolved or discussed with the resident. The grievance was marked as resolved in the log without the resident's signature or confirmation.
The facility did not report multiple allegations of abuse involving three cognitively intact residents to the State Survey Agency as required by policy. Incidents included verbal mistreatment, rough handling, and inappropriate language by CNAs. Although internal actions were taken, the required external reporting was not completed.
Two residents reported being hurt or mistreated by CNAs, but despite these allegations being brought to the attention of the DON and administrator, no formal investigation was conducted as required by facility policy. The CNAs involved were removed from the residents' care, but neither resident was interviewed about the incidents, and the DON considered the complaints to be customer service issues rather than potential abuse.
Failure to Provide Accessible Hydration: Two residents were observed without accessible water at their bedside, despite facility policy stating residents have a right to reasonable accommodation of needs. One cognitively intact resident with DM, CKD, ASHD, and MDD repeatedly had no water in her room and said she had to go to the nurse's desk for water after someone took her pitcher and did not return it. Another cognitively intact resident with DM, HF, CKD, and vitamin D deficiency had an empty pitcher placed across the room on a chest of drawers, out of reach from her bed, and stated she could not get to it. An LPN confirmed that residents should have accessible hydration at all times and that the pitcher should not be across the room.
A resident’s bathroom floor covering was removed, leaving bare concrete with a black stained area around the toilet base. Housekeeping said the area had been mopped but could not be cleaned properly and had been that way for some time, while maintenance said damaged flooring is sometimes removed down to bare concrete and staff would notify him when repairs were needed. The Administrator said she was unaware the floor covering was missing and acknowledged the resident should have had a floor covering. The resident had Huntington’s disease and was cognitively intact with a BIMS score of 15.
A CNA told a resident to shut up during repositioning when the resident complained of leg pain. The resident, who had cerebral palsy and chronic pain, said the comment made her sad and angry, and the CNA later admitted she should not have spoken to her that way.
Failure to implement orthotic devices for two residents with hand/wrist contractures. Both residents had OT discharge recommendations for restorative nursing orthotic wear/management to maintain ROM and prevent worsening contractures, but observations showed no orthotic in place and the residents reported the devices had not been used consistently. The DON confirmed there were no orders in the system and that the orthotics had not been implemented per OT recommendations.
Inaccurate MAR Documentation for Fentanyl Patch Administration: A resident with chronic pain and a cognitively intact BIMS score reported that a nurse did not apply his fentanyl patch on multiple occasions. Record review showed the MAR was initialed as if the patch had been administered, but the controlled drug record did not show the dose was signed out, and the DON confirmed the patch was not actually given on two scheduled changes even though it was documented as administered.
A resident with Dementia and Impulse Disorder was improperly restrained with a sheet tied to a wheelchair without physician orders, consent, or assessment. The facility's policy requires restraints only as a last resort, but the resident was found with a sheet tied around her waist. The Director of Nursing confirmed the incident but could not identify who applied the restraint. Additionally, the resident was using a mattress with elevated sides and foam wedges without proper documentation or orders.
A resident with Dementia and Impulse Disorder was found restrained with a sheet tied to a wheelchair, which was not reported to the State Agency. The DON believed it was for safety due to the resident's behaviors and falls, but the Administrator later acknowledged it as inappropriate treatment.
A resident in an LTC facility died after another resident, who was severely obese and had a history of delusional behavior, lay on top of him. The facility failed to identify roommate incompatibility or provide appropriate behavioral interventions, despite previous incidents of the obese resident being found in bed with other residents. This neglect placed residents at risk, resulting in a tragic death.
A resident with a history of delusional and aggressive behavior was not adequately monitored due to the facility's failure to update their care plan. This oversight led to a tragic incident where the resident was found in bed with another resident, who was later pronounced dead. Staff interviews confirmed that the care plan lacked necessary revisions and interventions to prevent such occurrences.
A resident with severe cognitive impairment and behavioral issues was inadequately supervised, leading to a fatal incident where he was found unclothed on top of another resident, resulting in the latter's death. Despite previous incidents of inappropriate behavior, the facility failed to update the resident's care plan or increase monitoring, placing all residents at risk.
A resident with mental disorders exhibited aggressive and inappropriate behaviors, which were not adequately monitored or addressed by the facility. Despite previous incidents of the resident being found in bed with others, the facility failed to implement necessary interventions or update care plans. This inaction led to a tragic incident where the resident was found unclothed on top of another resident, resulting in the latter's death. The State Agency identified Immediate Jeopardy and Substandard Quality of Care due to these deficiencies.
Missed fentanyl patch administrations for resident with chronic pain
Penalty
Summary
The facility failed to provide safe, appropriate pain management for a resident who required fentanyl patches for chronic pain. Resident #106, who was cognitively intact and had diagnoses including cervical spinal cord injury, hereditary and idiopathic neuropathy, chronic pain, and polyosteoarthritis, reported daily pain in 26 areas of his body and said he had been using fentanyl patches for about 19 months along with gabapentin, oxycodone, lidocaine patches, Biofreeze, and Tylenol as needed. The resident stated that a nurse on the 3-11 shift repeatedly failed to apply his fentanyl patch as ordered and that he had not received it correctly on four occasions during his stay. Record review showed the fentanyl transdermal patch order was to be applied every 72 hours, but the controlled drug record did not show a dose signed out on 7/30/25 or 8/5/25, indicating missed administrations. The resident’s pain documentation showed pain levels of 4/10 on 7/30/25, 5/10 on 8/1/25 and 8/2/25, and 10/10 on 8/5/25. RN #2 confirmed the missed fentanyl doses and acknowledged the physician orders were not followed. The DON also confirmed the patches were available and that the nurse failed to administer them as ordered.
Failure to Follow Care Plans for Hygiene and Pain Management
Penalty
Summary
The facility failed to implement care plans for residents who were dependent on staff for nail care, showers, and pain management. The facility policy stated that each resident would have a person-centered plan of care identifying problems, needs, strengths, preferences, goals, and how the interdisciplinary team would provide care. Record review and observations showed that Resident #6, who had Type 2 diabetes and was cognitively intact, had long fingernails and told staff he needed them trimmed; RN #2 confirmed the nails needed to be cut. Resident #16, who had Bipolar Disorder, hemiplegia and hemiparesis following cerebral infarction, and was dependent for personal hygiene, was observed with fingernails about one-half inch long with a brown substance underneath, and CNA #4 confirmed the condition of the nails. Resident #102, who had Major Depressive Disorder and an acquired absence of the left leg below the knee, was also observed with long fingernails and brown substance underneath, and the Administrator confirmed the nail care issue. The facility also failed to provide showers as planned for Resident #88 and Resident #94. Resident #88’s care plan included showering every other day with supervision, but she reported she had not had a shower or bath since the prior week, stated she did not refuse showers, and said no one offered her a shower on the weekend. She was observed with greasy hair, and LPN #4 confirmed she needed a shower. Resident #94, who had limited physical mobility and required extensive assistance with bathing, was observed lying in bed with greasy hair and mild body odor; she stated she had not had a shower or bath in a week and needed one. LPN #4 confirmed her greasy hair and body odor and stated her bath/shower days were Mondays, Wednesdays, and Fridays, noting she should have gotten a shower the day before. Resident #106’s pain management care plan was not followed as ordered. He had diagnoses including unspecified injury at an unspecified level of cervical spinal cord, hereditary and idiopathic neuropathy, chronic pain, and polyosteoarthritis, and he reported chronic pain in many areas of his body. His care plan included giving medications as ordered for pain, including a fentanyl patch. Review of the MAR and controlled drug record showed the fentanyl patch was not signed out on two occasions, and the resident stated he had not received the patch correctly on four separate occasions during his stay. RN #2 confirmed missed fentanyl doses, and the MDS nurse confirmed the care plan was not followed to give the fentanyl patch as ordered.
Missed showers and nail care for dependent residents
Penalty
Summary
The facility failed to provide basic hygiene care for dependent residents by not ensuring that showers and routine nail care were completed as scheduled. Facility policy stated that fingernails and toenails are to be kept trimmed and clean to prevent infections, and that a bath or shower for cleanliness and comfort is scheduled at least weekly for each resident. Survey observations, resident interviews, staff interviews, and record review showed that five residents did not receive the hygiene care identified in the report. Resident #6, who had Type 2 Diabetes Mellitus and a BIMS score of 15, was observed with long fingernails about 3/8 inch in length and stated that he had been trying to get help for a couple of days because he had "claws." RN #2 confirmed the nails were long and stated that, because the resident was diabetic, his nails had to be trimmed by a nurse and checked weekly. Resident #16, who had Bipolar Disorder, Hemiplegia and Hemiparesis following Cerebral Infarction, and was dependent with personal hygiene needs, was observed with long fingernails about one-half inch long on both hands with a brown substance underneath. CNA #4 and LPN #3 both confirmed the condition of the nails, and LPN #3 stated that nail care should be completed during bath/shower times and fingernails should be cleaned every day and as needed. Resident #102, who had Major Depressive Disorder and an acquired absence of the left leg below the knee, was also observed with long fingernails about one-half inch long on both hands with a brown substance underneath, and CNA #2 and the Administrator confirmed the finding. Resident #88, who had Type II Diabetes Mellitus and Bipolar Disorder and required supervision or touching assistance with showering and bathing, stated that she felt dirty and reported that she had not had a shower or bath since the prior Tuesday even though she normally received showers on Tuesdays, Thursdays, and Saturdays. She said no one offered her a shower on the missed day and that staff sometimes told her they were too busy. CNA #5 and LPN #4 confirmed that her hair appeared greasy and that she needed a shower. Resident #94, who had Hemiplegia and Hemiparesis following Cerebral Infarction and was dependent with bathing/showering and personal hygiene needs, was observed with greasy hair and a mild body odor and stated that staff were not giving baths as they were supposed to and that it had been about a week since her last one. LPN #4 confirmed that she should have received a bath the day before and that she had greasy hair and a mild body odor.
Failure to Resolve and Document Resident Grievance
Penalty
Summary
The facility failed to resolve a grievance submitted by a resident who reported that a CNA caused pain by jerking his legs during repositioning, which hurt his back. The resident stated he reported the incident to staff, but no one followed up with him regarding the complaint. The DON confirmed that a grievance form was completed on behalf of the resident, but the form was not signed by the resident, and there was no documentation indicating that the grievance had been resolved or discussed with the resident. The grievance log listed the complaint as resolved, but there was no evidence of communication with the resident or proper closure of the grievance. Social Services staff confirmed that grievances should be discussed with and signed by residents before being considered resolved.
Failure to Report Alleged Abuse to State Survey Agency
Penalty
Summary
The facility failed to ensure that all alleged abuse violations were reported to the State Survey Agency as required by its own policy. The policy mandates immediate reporting of alleged abuse, neglect, or theft to the administrator and appropriate authorities, including the State Survey Agency, within specified timeframes. However, for three of five reviewed cases involving alleged abuse, the facility did not report the incidents as required. In one instance, a resident with a history of major depressive disorder, anxiety, pain, and cerebral palsy reported that a CNA told her to "shut up" when she complained of leg pain during repositioning. The resident reported the incident to the former administrator, who initiated an internal investigation but did not report the allegation to the State Survey Agency, believing it did not constitute abuse. In another case, a cognitively intact resident with paraplegia reported that two CNAs hurt him during care, including being jerked and slapped with a wet towel. The resident stated that no one followed up with him about his complaint, although the CNAs were removed from his care. A third resident, also cognitively intact and with diagnoses including anxiety, pain, and hemiplegia, reported to the DON that a CNA hurt him during care and spoke to him inappropriately. The DON acknowledged receiving the complaint but considered it a customer service issue and did not report it to the state. In all three cases, the facility failed to follow its policy for reporting alleged abuse to the State Survey Agency, as confirmed by interviews with staff and review of facility records.
Failure to Investigate Alleged Abuse Reports
Penalty
Summary
The facility failed to investigate allegations of abuse for two of five residents reviewed, as required by its own policy. One resident reported to staff that two CNAs had hurt him while turning him, and also reported to the administrator that another CNA had slapped his face with a wet towel during a bed bath. The resident stated that after making these reports, the CNAs involved no longer worked with him, but no one from the facility had followed up or interviewed him about the incidents. Another resident reported that a CNA attempted to turn him alone, causing pain, and sometimes spoke to him in an unkind manner. He reported this to the DON, after which the CNA was removed from his care, but again, no investigation or follow-up interview was conducted. Interviews with the DON confirmed awareness of the complaints and that the CNAs were removed from providing care to the residents involved, but no formal investigation was initiated because the DON considered the issues to be customer service concerns rather than abuse. The DON also admitted that an investigation should have been conducted, especially after one resident was sent to the emergency room for back pain following his complaint. The facility's policy requires immediate investigation of any potential abuse or neglect, but this was not followed in these cases. Both residents involved had significant medical histories, including paraplegia and hemiplegia, and were cognitively intact at the time of the incidents.
Failure to Provide Accessible Hydration
Penalty
Summary
The facility failed to ensure reasonable accommodation of resident needs by not providing accessible oral hydration for two residents. Facility policy stated that each resident has a right to reside and receive services with reasonable accommodation of resident needs. Resident #38, who was cognitively intact with a BIMS score of 13 and had diagnoses including Type 2 DM with diabetic CKD, ASHD, and major depressive disorder, was observed multiple times sitting in her room without water in a pitcher or cup. She stated she had to go up the hall to get water, and later said someone took her water pitcher and did not return it. An LPN confirmed that residents are to have a water pitcher in their room unless they are on thickened liquids or cannot drink, and that hydration should be accessible at all times. Resident #47, who was cognitively intact with a BIMS score of 15 and had diagnoses including Type 2 DM, vitamin D deficiency, HF, and CKD, was observed with an empty water pitcher sitting across the room on top of a chest of drawers, out of reach from her bed. She stated she could not walk over to get it and had no water at her bedside, only what she had at lunch. Later observations again showed no accessible water at her bedside and the pitcher still across the room and empty. An LPN confirmed the pitcher was inaccessible and stated it should never be sitting across the room, and that residents are supposed to be offered hydration and have it accessible at their bedside.
Bathroom Floor Covering Removed and Area Left Stained
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for Resident #43 when the bathroom floor covering had been removed, leaving bare concrete with a black stained area around the toilet base. The report states the facility did not have a policy regarding maintenance repairs, and the Administrator signed a typed statement on facility letterhead acknowledging that fact. On observation, the resident’s bathroom floor covering was missing, and the floor was bare concrete with a black substance around the toilet. Housekeeping staff stated the area had been mopped but could not be cleaned properly and had been that way for some time. Maintenance staff stated that when flooring is torn or damaged, linoleum is sometimes removed down to bare concrete, and that aides, nurses, or housekeepers would notify him when repairs were needed. The Administrator stated she was unaware the bathroom floor covering had been removed and acknowledged the resident should have a floor covering. Resident #43 was admitted with Huntington’s Disease, and the MDS showed a BIMS score of 15, indicating the resident was cognitively intact.
Verbal Abuse During Resident Care
Penalty
Summary
The facility failed to protect a resident’s right to be free from verbal abuse when a CNA told Resident #3 to “shut up” during care. The resident, who had diagnoses including cerebral palsy, pain, major depressive disorder, and anxiety disorder, was being repositioned in bed when she complained that her legs were hurting. The CNA responded that the resident’s legs were not hurting and then told her to shut up after the resident repeated the same phrase back to her. The CNA later acknowledged that she should not have spoken to the resident that way. Resident #3 stated that the comment made her sad and angry and that she had reported the incident to the former Administrator. The former Administrator stated she received a call from the Ombudsman about the resident’s complaint and spoke with the resident, who said the CNA told her to shut up while trying to prop a pillow under her legs. The resident was cognitively intact with a BIMS score of 15, and she stated she did not want that CNA to care for her anymore. Facility records and interviews confirmed the verbal exchange occurred during resident care.
Failure to Implement Orthotic Devices for Residents With Contractures
Penalty
Summary
The facility failed to provide restorative nursing services for two residents with contractures by not implementing orthotic devices after therapy discharge recommendations. Resident #16, who had diagnoses including bipolar disorder and hemiplegia/hemiparesis following cerebral infarction and was cognitively intact with a BIMS score of 15, was observed sitting in a wheelchair and later lying in bed with a contracture to the left wrist/hand and no orthotic device in place. Her OT discharge summary stated she was discharged with an orthotic, and restorative nursing staff were trained on PROM exercises and donning/doffing the orthotic, but the resident reported that staff only sometimes rolled a towel in her hand and she could not remember the last time it was applied. Resident #94, who also had hemiplegia/hemiparesis following cerebral infarction and a BIMS score of 15, was observed lying in bed feeding herself with her right hand while her left wrist/hand contracture had no orthotic device in place. She stated that staff used to put something in her hand to keep it open, but it had been over a month since it was used. Her OT discharge summary stated that restorative nursing had been established for orthotic wear/management to maintain current ROM and reduce the risk for further contracture. The DON confirmed there were no orders in the system for the orthotics and that the orthotics had not been implemented per recommendations, and restorative LPN staff stated they were not aware of the prior recommendations for either resident.
Inaccurate MAR Documentation for Fentanyl Patch Administration
Penalty
Summary
The facility failed to maintain accurate medical records for one resident’s medication administration. Resident #106 stated that a nurse on the 3-11 shift did not apply his fentanyl patch on multiple occasions and reported that the last missed application occurred on August 5, when he did not receive the patch until August 6. The resident had been admitted with diagnoses including unspecified injury at an unspecified level of cervical spinal cord, hereditary and idiopathic neuropathy, chronic pain, and polyosteoarthritis, and his MDS showed a BIMS score of 15, indicating he was cognitively intact. Record review showed an order for fentanyl transdermal patch 75 mcg/hr every 72 hours. The July 2025 MAR was initialed as administered for the scheduled change due on 7/30/25, but the fentanyl controlled drug record was not signed out that day. The August 2025 MAR was also initialed as given for the scheduled change due on 8/5/25, but the controlled drug record again showed no dose signed out. The DON reviewed the narcotic record and confirmed the patch was not given on 7/30 and 8/5, but was signed off on the MAR as if it had been administered. The Administrator stated medications were expected to be given as ordered and signed off immediately after administration, and agreed the resident’s medical record was not accurate.
Improper Use of Physical Restraints Without Physician Orders
Penalty
Summary
The facility failed to prevent a resident from being physically restrained with a sheet tied to a wheelchair, without obtaining physician orders, consent, or conducting an assessment for the need of restraints. The incident involved a resident who was observed with a sheet tied around her waist and knotted behind the wheelchair. Several Certified Nursing Assistants (CNAs) reported seeing the resident restrained in this manner, and one CNA reported the situation to a Licensed Practical Nurse (LPN), who allegedly stated it was for the resident's safety. However, the LPN later denied any knowledge of the restraint or instructing staff to use it. The facility's policy, in accordance with the Omnibus Budget Reconciliation Act (OBRA) requirements, states that all residents have the right to be unrestrained, and restraints should only be used as a last resort with proper evaluation and physician orders. Despite this, the facility did not have any physician's orders, consents, or assessments for the use of a mattress with elevated sides and foam wedges that were also in place for the resident. The Director of Nursing (DON) confirmed that an investigation was conducted, but they were unable to determine who applied the restraint. The DON believed the restraint was used for the resident's safety due to recent combative behavior and sliding in the wheelchair. The resident involved had been admitted to the facility with diagnoses including Dementia and Impulse Disorder. The facility's Daily Care Guide for the resident did not list any interventions for the use of foam wedges, and there were no physician's orders for the mattress with elevated sides or wedges. The Unit Manager emphasized that restraints should never be applied without assessment, physician orders, and family consent, as they pose a risk of injury, such as sliding and choking.
Failure to Report Resident Restraint Incident
Penalty
Summary
The facility failed to report an allegation of mistreatment involving a resident who was physically restrained with a sheet tied to a wheelchair. The incident involved a resident with diagnoses of Dementia and Impulse Disorder, who was dependent on a wheelchair for locomotion. On 6/9/24, four CNAs observed the resident restrained with a sheet tied around the wheelchair. One CNA reported seeing the resident restrained twice on the same day, with a co-worker indicating that a nurse had instructed not to remove the sheet for the resident's safety. The Director of Nursing (DON) was informed of the incident on 6/10/24 and conducted an investigation. Despite the findings, the facility did not report the incident to the State Agency, as the DON believed it was done for the resident's safety due to her behaviors and falls. The facility was unable to determine who restrained the resident. The Administrator later agreed that using a sheet to restrain the resident was inappropriate and should have been reported as mistreatment.
Neglect and Inadequate Behavioral Interventions Lead to Resident Death
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in a tragic incident where one resident died after another resident, who was severely obese and had a history of delusional behavior, lay on top of him. The facility did not identify roommate incompatibility or provide appropriate person-centered behavioral interventions, which placed the deceased resident and others at risk. The incident occurred after the staff responded to a call light and found the obese resident unclothed and lying on top of the deceased resident, who was unresponsive and later pronounced dead. Prior to the incident, there were multiple occasions where the obese resident was found in bed with other residents, including a deaf and mute resident, but these incidents were not thoroughly investigated or addressed by the facility. Staff interviews revealed that the obese resident had a history of delusional episodes and had been observed inappropriately in bed with roommates on previous occasions. Despite these warning signs, the facility did not implement increased monitoring or update the resident's care plan to prevent further incidents. The facility's neglect to address the behavioral issues and roommate incompatibility of the obese resident led to a situation where other residents were at risk of harm. The staff failed to recognize the potential for abuse and did not take necessary actions to protect vulnerable residents, resulting in the death of one resident and placing others in jeopardy.
Removal Plan
- Resident #1 was placed on one-on-one supervision immediately. Psychiatric placement was initiated but was unsuccessful. A telehealth visit was conducted with the psychiatric nurse practitioner. Resident #1 remained on one-on-one supervision until he was discharged to the custody of the local police department.
- The Administrator presented to the facility and initiated an investigation with assigned licensed nurses and certified nursing assistants.
- The Administrator notified the MS State Department of Health, Attorney General Office, and Ombudsman.
- An in-service was initiated for all staff regarding supervision of accidents and incidents, abuse/neglect, how to handle resident to resident altercations, reporting of any resident with delusional behaviors or verbalizing harmful behaviors to others, how to deal with aggressive behaviors.
- A special resident council meeting was conducted by the Administrator and Director of Nurses to ensure that the facility's residents felt safe. 21 out of 21 Residents verbalized feeling safe in the facility.
- The social service department completed a 100% audit on roommate compatibility. 100% of the roommates were compatible or chose to be roommates.
- An in-service was initiated by the President of Operations for all staff on prevention/supervision of accidents, abuse/neglect, abuse reporting, resident rights, implementing interventions to prevent reoccurrence and updating care plans to reflect interventions and monitoring of behaviors. In-service details: When residents are observed in another resident's bed to immediately intervene and separate. The staff was instructed to notify the nurse immediately and protect the alleged victim by remaining one-on-one supervision with the alleged aggressor. The nurses were instructed to immediately perform head to toe skin assessments for both Residents while ensuring and notifying the Executive Director and Director of Nurses. The Administrator and Director of Nurses were instructed to ensure that a thorough investigation is completed and reported to the state agencies. The Administrator and Director of Nurses was instructed to ensure that interventions are put in place to protect other Residents and the alleged aggressor's care plan is updated and behavior is monitoring is in place. In-service also included notifying the nurse, Administrator, and Director of nurses immediately if any Resident verbalize or exhibits delusional behaviors that are harmful towards others. No staff will be allowed to work until the in-service is received.
- The President of Operations in serviced the Administrator and Director of Nurses on abuse/neglect and ensuring to investigate and report all instances of abuse/neglect to regulatory agencies.
- The President of Operations in serviced the social service department on ensuring that care plans are revised to reflect interventions and behaviors are monitored.
- An interview was initiated for 28 cognitive residents to determine if they have incurred any issues with other residents lying in their beds. 28 of 28 Residents denied any concerns.
- A 100% audit was initiated by the social services department to ensure that all Residents had compatible roommates. No issues identified.
- A 100% audit was conducted by the social services department to ensure that Residents' behaviors are care planned and monitoring is in place.
- The Administrator reported the incident involving Resident #1 and Resident #3 to the Mississippi State Department of Health.
- An emergency quality assurance committee met. The attendees of the meeting were the Administrator, Director of Nurses, Assistant Director of Nurses, Social Services Assistant, Staff Development Coordinator, Nurse Practitioner, Regional Clinical Operations Nurse, and Regional President. The facility discussed the current survey IJ outcomes. 5 IJ were cited for abuse/neglect, abuse reporting, revision of care plans, behavioral monitoring, and accidents/incidents. Upon investigation, Resident #1 had previous behavioral issues with Resident #3. Resident #1 was unclothed. The facility failed to report, investigate and implement interventions based on the behaviors. In-services modified to include protecting residents from others who get into their beds by intervening and providing one-on-one supervision. In addition, reporting and investigating alleged events. All policies were reviewed for accidents/incidents, abuse prevention, revision of care plans, behavioral monitoring. No changes required.
- The Ombudsman was notified of the incident.
- The Administrator reported the incident involving Resident #1 and Resident #3 to the Attorney General Office online system.
Failure to Revise Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to revise a comprehensive care plan for a resident known to exhibit behaviors of getting into bed with other residents. This failure resulted in staff not having access to preventative measures to deter such behavior. On one occasion, the resident was found in bed on top of another resident, who was unresponsive and later pronounced dead. This incident placed all residents at risk and was likely to cause serious injury, harm, impairment, or death. The care plan for the resident in question did not include revisions to address the behavior of getting into other residents' beds, despite previous incidents being documented. Staff interviews revealed that the care plan was not updated to reflect these behaviors, and no increased monitoring or interventions were put in place. The resident had a history of delusional, aggressive, and socially inappropriate behavior, and was severely cognitively impaired, which further necessitated the need for a revised care plan. Interviews with facility staff, including the Social Service worker and the Director of Nurses, confirmed that the care plan should have been updated to include one-on-one observation and increased monitoring. The failure to update the care plan and implement necessary interventions left other residents vulnerable to harm, as the resident was ambulatory and could have entered any resident's bed, posing a risk of accidental harm or abuse.
Removal Plan
- Resident #1 was placed on one-on-one supervision immediately. Psychiatric placement was initiated but was unsuccessful. A telehealth visit was conducted with the psychiatric nurse practitioner. Resident #1 remained on one-on-one supervision until he was discharged to the custody of the local police department.
- The Administrator presented to the facility and initiated an investigation with assigned licensed nurses and certified nursing assistants.
- The Administrator notified the MS State Department of Health, Attorney General Office, and Ombudsman.
- An in-service was initiated for all staff regarding supervision of accidents and incidents, abuse/neglect, how to handle resident to resident altercations, reporting of any resident with delusional behaviors or verbalizing harmful behaviors to others, how to deal with aggressive behaviors.
- A special resident council meeting was conducted by the Administrator and Director of Nurses to ensure that the facility's residents felt safe. 21 out of 21 Residents verbalized feeling safe in the facility.
- The social service department completed a 100% audit on roommate compatibility. 100% of the roommates were compatible or chose to be roommates.
- An in-service was initiated by the President of Operations for all staff on prevention/supervision of accidents, abuse/neglect, abuse reporting, resident rights, implementing interventions to prevent reoccurrence and updating care plans to reflect interventions and monitoring of behaviors. In-service details: When residents are observed in another resident's bed to immediately intervene and separate. The staff was instructed to notify the nurse immediately and protect the alleged victim by remaining one-on-one supervision with the alleged aggressor. The nurses were instructed to immediately perform head to toe skin assessments for both Residents while ensuring and notifying the Executive Director and Director of Nurses. The Administrator and Director of Nurses were instructed to ensure that a thorough investigation is completed and reported to the state agencies. The Administrator and Director of Nurses were instructed to ensure that interventions are put in place to protect other Residents and the alleged aggressor's care plan is updated and behavior is monitoring is in place. In-service also included notifying the nurse, Administrator, and Director of nurses immediately if any Resident verbalize or exhibits delusional behaviors that are harmful towards others. No staff will be allowed to work until the in-service is received.
- The President of Operations in serviced the Administrator and Director of Nurses on abuse/neglect and ensuring to investigate and report all instances of abuse/neglect to regulatory agencies.
- The President of Operations in serviced the social service department on ensuring that care plans are revised to reflect interventions and behaviors are monitored.
- An interview was initiated for 28 cognitive residents to determine if they have incurred any issues with other residents lying in their beds. 28 of 28 Residents denied any concerns.
- A 100% audit was initiated by the social services department to ensure that all Residents had compatible roommates. No issues identified.
- A 100% audit was conducted by the social services department to ensure that Residents' behaviors are care planned and monitoring is in place.
- The Administrator reported the incident involving Resident #1 and Resident #3 to the MS State Department of Health.
- An emergency quality assurance committee met. The attendees of the meeting were the Administrator, Director of Nurses, Assistant Director of Nurses, Social Services Assistant, Staff Development Coordinator, Nurse Practitioner, Regional Clinical Operations Nurse, and Regional President. The facility discussed the current survey IJ outcomes. 5 IJ cites for abuse/neglect, abuse reporting, revision of care plans, behavioral monitoring, and accidents/incidents. Upon investigation, Resident #1 had previous behavioral issues with Resident #3. Resident #1 was unclothed. The facility failed to report, investigate and implement interventions based on the behaviors. In-services modified to include protecting residents from others who get into their beds by intervening and providing one-on-one supervision. In addition, reporting and investigating alleged events. All policies were reviewed for accidents/incidents, abuse prevention, revision of care plans, behavioral monitoring. No changes required.
- The Ombudsman was notified of the incident.
- The Administrator reported the incident involving Resident #1 and Resident #3 to the Attorney General Office online system.
Inadequate Supervision Leads to Resident Death
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for residents with behavioral needs, leading to a tragic incident involving two residents. Resident #1, who was severely cognitively impaired and had a history of behavioral issues, was found unclothed and lying on top of Resident #2, resulting in Resident #2's death. Prior to this incident, Resident #1 had been observed in bed with another resident, Resident #3, but no increased monitoring or interventions were implemented despite the potential risk. The facility's records indicate that Resident #1 had been admitted with diagnoses including unspecified mood affective disorder, unspecified psychosis, and anxiety disorder. Despite these conditions and previous incidents of inappropriate behavior, such as getting into bed with other residents, the facility did not update Resident #1's care plan or increase supervision. Staff interviews revealed that the potential for harm was not recognized, and no actions were taken to prevent further incidents. The lack of appropriate interventions and monitoring placed all residents at risk, particularly those who were vulnerable, such as Resident #3, who was deaf and mute. The facility's failure to act on previous incidents and the absence of a proactive approach to managing Resident #1's behaviors directly contributed to the fatal incident involving Resident #2.
Removal Plan
- Resident #1 was placed on one-on-one supervision immediately. Psychiatric placement was initiated but was unsuccessful. A telehealth visit was conducted with the psychiatric nurse practitioner. Resident #1 remained on one-on-one supervision until he was discharged to the custody of the local police department.
- The Administrator presented to the facility and initiated an investigation with assigned licensed nurses and certified nursing assistants.
- The Administrator notified the MS State Department of Health, Attorney General Office, and Ombudsman.
- An in-service was initiated for all staff regarding supervision of accidents and incidents, abuse/neglect, how to handle resident to resident altercations, reporting of any resident with delusional behaviors or verbalizing harmful behaviors to others, how to deal with aggressive behaviors.
- A special resident council meeting was conducted by the Administrator and Director of Nurses to ensure that the facility's residents felt safe. 21 out of 21 Residents verbalized feeling safe in the facility.
- The social service department completed a 100% audit on roommate compatibility. 100% of the roommates were compatible or chose to be roommates.
- An in-service was initiated by the President of Operations for all staff on prevention/supervision of accidents, abuse/neglect, abuse reporting, resident rights, implementing interventions to prevent reoccurrence and updating care plans to reflect interventions and monitoring of behaviors. In-service details: When residents are observed in another resident's bed to immediately intervene and separate. The staff was instructed to notify the nurse immediately and protect the alleged victim by remaining one-on-one supervision with the alleged aggressor. The nurses were instructed to immediately perform head to toe skin assessments for both Residents while ensuring and notifying the Executive Director and Director of Nurses. The Administrator and Director of Nurses were instructed to ensure that a thorough investigation is completed and reported to the state agencies. The Administrator and Director of Nurses was instructed to ensure that interventions are put in place to protect other Residents and the alleged aggressor's care plan is updated and behavior is monitoring is in place. In-service also included notifying the nurse, Administrator, and Director of nurses immediately if any Resident verbalize or exhibits delusional behaviors that are harmful towards others. No staff will be allowed to work until the in-service is received.
- The President of Operations in serviced the Administrator and Director of Nurses on abuse/neglect and ensuring to investigate and report all instances of abuse/neglect to regulatory agencies.
- The President of Operations in serviced the social service department on ensuring that care plans are revised to reflect interventions and behaviors are monitored.
- An interview was initiated for 28 cognitive residents to determine if they have incurred any issues with other residents lying in their beds. 28 of 28 Residents denied any concerns.
- A 100% audit was initiated by the social services department to ensure that all Residents had compatible roommates. No issues identified.
- A 100% audit was conducted by the social services department to ensure that Residents' behaviors are care planned and monitoring is in place.
- The Administrator reported the incident involving Resident #1 and Resident #3 to the MS State Department of Health.
- An emergency quality assurance committee met. The attendees of the meeting were the Administrator, Director of Nurses, Assistant Director of Nurses, Social Services Assistant, Staff Development Coordinator, Nurse Practitioner, Regional Clinical Operations Nurse, and Regional President. The facility discussed the current survey IJ outcomes. 5 IJ cites for abuse/neglect, abuse reporting, revision of care plans, behavioral monitoring, and accidents/incidents. Upon investigation, Resident #1 had previous behavioral issues with Resident #3. Resident #1 was unclothed. The facility failed to report, investigate and implement interventions based on the behaviors. In-services modified to include protecting residents from others who get into their beds by intervening and providing one-on-one supervision. In addition, reporting and investigating alleged events. All policies were reviewed for accidents/incidents, abuse prevention, revision of care plans, behavioral monitoring. No changes required.
- The Ombudsman was notified of the incident by the Administrator.
- The Administrator reported the incident involving Resident #1 and Resident #3 to the Attorney General Office online system.
Failure to Address Resident Behaviors Leads to Fatal Incident
Penalty
Summary
The facility failed to recognize and appropriately address the behaviors of a resident diagnosed with mental disorders, leading to a tragic incident. The resident, who was admitted with diagnoses including Unspecified Mood Affective Disorder, Unspecified Psychosis, and Anxiety Disorder, exhibited behaviors such as physical aggression, verbal aggression, delusions, and inappropriate social interactions. Despite these documented behaviors, the facility did not implement adequate monitoring or interventions, resulting in the resident being found unclothed and lying on top of another resident, who subsequently died. Prior to the incident, there were multiple occasions where the resident was found inappropriately in bed with other residents, yet the facility did not increase monitoring or update the care plan to address these behaviors. Staff interviews revealed that the resident was not placed on special monitoring before the incident, and there was a lack of documentation and follow-up on the resident's behavior. The facility's failure to act on these warning signs and implement person-centered behavioral interventions contributed to the incident. The State Agency identified Immediate Jeopardy and Substandard Quality of Care due to the facility's inaction, which placed other residents at risk. The facility's policies on behavior management and monitoring were not effectively followed, leading to a failure in providing a safe environment for all residents. The lack of appropriate supervision and intervention for the resident's behaviors ultimately resulted in the death of another resident, highlighting significant deficiencies in the facility's care practices.
Removal Plan
- Resident #1 was placed on one-on-one supervision immediately. Psychiatric placement was initiated but was unsuccessful. A telehealth visit was conducted with the psychiatric nurse practitioner. Resident #1 remained on one-on-one supervision until he was discharged to the custody of the local police department.
- The Administrator presented to the facility and initiated an investigation with assigned licensed nurses and certified nursing assistants.
- The Administrator notified the MS State Department of Health, Attorney General Office, and Ombudsman.
- An in-service was initiated for all staff regarding supervision of accidents and incidents, abuse/neglect, how to handle resident to resident altercations, reporting of any resident with delusional behaviors or verbalizing harmful behaviors to others, how to deal with aggressive behaviors.
- A special resident council meeting was conducted by the Administrator and Director of Nurses to ensure that the facility's residents felt safe. 21 out of 21 Residents verbalized feeling safe in the facility.
- The social service department completed a 100% audit on roommate compatibility. 100% of the roommates were compatible or chose to be roommates.
- An in-service was initiated by the President of Operations for all staff on prevention/supervision of accidents, abuse/neglect, abuse reporting, resident rights, implementing interventions to prevent reoccurrence and updating care plans to reflect interventions and monitoring of behaviors. In-service details: When residents are observed in another resident's bed to immediately intervene and separate. The staff was instructed to notify the nurse immediately and protect the alleged victim by remaining 1-on-1 supervision with the alleged aggressor. The nurses were instructed to immediately perform head to toe skin assessments for both Residents while ensuring and notifying the Executive Director and Director of Nurses. The Administrator and Director of Nurses were instructed to ensure that a thorough investigation is completed and reported to the state agencies. The Administrator and Director of Nurses was instructed to ensure that interventions are put in place to protect other Residents and the alleged aggressor's care plan is updated and behavior is monitoring is in place. In-service also included notifying the nurse, Administrator, and Director of nurses immediately if any Resident verbalize or exhibits delusional behaviors that are harmful towards others. No staff will be allowed to work until the in-service is received.
- The President of Operations in serviced the Administrator and Director of Nurses on abuse/neglect and ensuring to investigate and report all instances of abuse/neglect to regulatory agencies.
- The President of Operations in serviced the social service department on ensuring that care plans are revised to reflect interventions and behaviors are monitored.
- An interview was initiated for 28 cognitive residents to determine if they have incurred any issues with other residents lying in their beds. 28 of 28 Residents denied any concerns.
- A 100% audit was initiated by the social services department to ensure that all Residents had compatible roommates. No issues identified.
- A 100% audit was conducted by the social services department to ensure that Residents' behaviors are care planned and monitoring is in place.
- The Administrator reported the incident involving Resident #1 and Resident #3 to the MS State Department of Health.
- An emergency quality assurance committee met. The attendees of the meeting were the Administrator, Director of Nurses, Assistant Director of Nurses, Social Services Assistant, Staff Development Coordinator, Nurse Practitioner, Regional Clinical Operations Nurse, and Regional President. The facility discussed the current survey IJ outcomes. 5 IJ cites for abuse/neglect, abuse reporting, revision of care plans, behavioral monitoring, and accidents/incidents. Upon investigation, Resident #1 had previous behavioral issues with Resident #3. Resident #1 was unclothed. The facility failed to report, investigate and implement interventions based on the behaviors. In-services modified to include protecting residents from others who get into their beds by intervening and providing 1-on-1 supervision. In addition, reporting and investigating alleged events. All policies were reviewed for accidents/incidents, abuse prevention, revision of care plans, behavioral monitoring. No changes required.
- The Ombudsman was notified of the incident.
- The Administrator reported the incident involving Resident #1 and Resident #3 to the Attorney General Office online system.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 21 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ruleville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Walter B Crook Nursing Facility | 0.2 mi | ★★★★★ | 7 | 0 |
| Cleveland Community Care Center | 8.9 mi | ★★★★★ | 8 | 0 |
| Bolivar Medical Center Ltc | 9.5 mi | ★★★★★ | 0 | 0 |
| Delta Rehabilitation And Healthcare Center | 9.6 mi | ★★★★★ | 0 | 0 |
| Diversicare Of Shelby | 19.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.