The incident at Medilodge of Marshall involved two roommates with vastly different cognitive abilities.
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R3 described the experience to inspectors: "We ran out of toilet paper last week.
Night shift staff were described as loud and using profanity, preventing residents from sleeping.
Graduate Practical Nurse #1 started work at Diversicare of Amory on July 15, 2025, fresh from nursing school.
Resident #1's call light sat on the floor approximately two feet to the right of the bed.
The facility's doctor determined he needed inpatient geriatric psychiatric treatment and deemed it unsafe to have him near other vulnerable residents.
The facility's own protocol required such evaluations after unwitnessed falls.
The incident occurred at Saint John Paul II Center on July 22, when Resident #2 fell sometime around 2:50 AM.
The only psychiatric diagnosis listed was major depressive disorder.
The failures affected residents with cognitive impairments who required substantial assistance with personal care.
The patient, identified as Resident #10 in federal inspection records, suffered from dementia, schizophrenia and respiratory failure.
The family member pressed facility leadership for an explanation.