The January 18 attack was one of three separate incidents of resident-on-resident violence that administrators failed to report to Louisiana health officials, federal inspectors found during a February 11 complaint investigation.
In each case, facility leaders acknowledged the incidents constituted abuse but claimed they didn't recognize their reporting obligations.
The most serious incident occurred when Resident #1 punched Resident #2 during an argument in their shared room at 6:30 p.m. on January 18. Nursing assistant S7CNA witnessed the attack and immediately notified licensed practical nurse S4LPN.
But S4LPN didn't report the incident to anyone else until January 20, when Resident #1's right hand had swollen noticeably. A mobile X-ray that day revealed a 5th Metacarpal Neck Fracture of the Right Hand.
"She stated a resident punching another resident was physical abuse and should be reported," inspectors wrote after interviewing S4LPN. "She stated she knew to report it, but she failed to do so on 01/18/2025."
The administrator, identified as S1ADM, confirmed he learned about the assault on January 20. "He confirmed the incident was abuse, should have been reported on 01/18/2025, and was not," the inspection report states.
Administrator S2CON, who was responsible for state reporting during the period, disagreed. When inspectors interviewed her on February 11, "she stated this incident was not physical abuse."
The pattern of unreported violence stretched back to December. On December 18, Resident #1 approached the nurses' station with blood on his hands and announced, "I f***ed him up," referring to his roommate Resident #4.
Staff found Resident #4 with scratches on his left arm and Resident #1 with a deep laceration between his thumb and pointer finger. Resident #1 explained his motivation to staff: "Everyday he is just sleeping and I'm tired of it."
Both residents involved in the December incident were cognitively intact, according to their most recent assessments. Resident #1 scored 13 on his Brief Interview for Mental Status, as did Resident #4.
Six days before Christmas, violence erupted again. On December 24 at 11:45 a.m., Resident #2 slapped Resident #3 in the face. Licensed practical nurse S3LPN was notified by certified nursing assistant S6CNA immediately after the assault.
Resident #3 also tested as cognitively intact, with a BIMS score of 13 on her November assessment.
Administrator S1ADM told inspectors he was aware of all three incidents from December 18, December 24, and January 18. "He confirmed the incidents were abuse, should have been reported to state agency, and were not."
But S2CON, who held administrator duties during the December and January period, maintained a different position. "She stated these incidents were not physical abuse, and therefore she did not report them to the state agency."
The confusion extended beyond incident reporting to basic psychiatric care requirements. Two residents received new mental health diagnoses after admission but never received required specialized evaluations.
Resident #1 was diagnosed with Unspecified Psychosis on December 19, 2024. Resident #2 received a Bipolar Disorder diagnosis on January 2, 2025. Federal regulations require facilities to submit residents for Level II psychiatric evaluations when they develop new mental health conditions after admission.
Neither resident received the required evaluation.
Social worker S11SW, responsible for filing psychiatric screening paperwork, told inspectors she was "unsure who was responsible for completing resident assessments following a new psychiatric diagnosis after admission, and who was responsible for submitting a new Resident Review to determine candidacy for Level II services."
Administrator S1ADM acknowledged the oversight. After reviewing both residents' diagnoses, "he confirmed they acquired new psychiatric diagnoses since Level I approval, and a new Level I Pre-admission Screening and Resident Review was not completed and should have been."
S2CON also claimed ignorance about the psychiatric evaluation requirements. "She stated she was unaware of who was responsible for ensuring residents received evaluations for PASRR determination of services after new psychiatric diagnoses."
The facility's incident log from December 2024 through January 2025 documented the pattern of physical aggression between residents, but the required state notifications never followed.
Resident #1, who appeared in two of the three violent incidents, had been admitted with diagnoses including Schizophreniform Disorder and later Schizophrenia. His cognitive assessment scores indicated he understood his actions.
The January 18 punch that broke his roommate's hand occurred during what nursing assistant S7CNA described as an argument between the two men. She witnessed Resident #1 throw the punch and immediately reported it to the licensed practical nurse on duty.
The two-day delay in reporting meant state officials couldn't immediately investigate the circumstances or ensure proper protective measures for other residents.
Federal inspectors classified the violations as causing "actual harm" to "some" residents. The facility's failure to report abuse incidents and conduct required psychiatric evaluations left vulnerable residents without proper protections and services.
The inspection revealed a facility where administrators disagreed about basic reporting requirements even as residents with serious mental health conditions attacked each other repeatedly over a two-month period.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mid City Community Nursing and Rehab from 2025-02-11 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Mid City Community Nursing and Rehab
- Browse all LA nursing home inspections
