Legacy Nursing At St. Christina

Observation on 09/29/2025 at 10:40 a.m. revealed Resident #2 had periorbital bruising to the left eye.

Interview with Resident #2 at this time revealed he was hit in the eye by another resident. Resident #4

Review of the clinical record for Resident #4 revealed an original admit date of 06/12/2025 with a re-entry date of 09/17/2025 with diagnoses that include in part.

Bipolar Disorder; Episodic Manic Severe with Psychotic Features; Anxiety; Depression; Moderate Intellectual Disabilities; Congestive Heart Failure; and Chronic Obstructive Pulmonary Disease.

Review of Resident #4's admission MDS with an ARD of 06/24/2025 revealed Resident #4 had a BIMS score of 4, indicating severely impaired cognition. Resident #4 required minimal assistance with ADLs.

Review of Resident #4's care plan dated 06/13/2025 read in part. I display behavior related to Impulse Disorder and Moderate Intellectual Disabilities. On 09/21/2025 my roommate was trying to stop me from leaving my room and trying to bite me, so I made contact with roommate.

Interview on 09/29/2025 at 11:47 a.m. with Resident #4 revealed that Resident #2 was lying on a mat on the floor, attempting to hit and bite Resident #4's legs. Resident #4 reported that the behavior made him angry, and he struck Resident #2 with his left fist. Resident #4 experienced pain and swelling of the left hand following the altercation and, an x-ray was ordered.

Observation of Resident #4's left hand revealed minimal swelling. On 09/29/2025 at 1:18 p.m., a telephone interview with S4 Nurse Practitioner revealed she was notified of the altercation on 09/21/2025 and was informed that Resident #2 sustained facial bruising and bleeding from his nose and left ear. Resident #2 was subsequently sent to the Emergency Department for evaluation and treatment. On 09/29/2025 at 3:51 p.m., an interview with S5 CNA reported that following the incident on 09/21/2025, Resident #4 verbalized to him that he struck Resident #2 in the face because Resident #2 was messing with his legs. On 09/29/2025 at 4:05 p.m., an interview with S6 CNA reported that on 09/21/2025, prior to the physical altercation, Resident #4 threatened Resident #2, stating, If he keeps bothering me, I will blacken his eyes. S6 CNA confirmed she reported these threats immediately to S3 LPN. On 09/29/2025 at 4:30 p.m., an interview with S7 CNA revealed that on 09/21/2025, prior to the physical altercation, Resident #4 threatened Resident #2, stating, I'm going to kill or break his arms if he doesn't stop bothering me. S7 CNA confirmed she reported these threats immediately to S3 LPN. On 09/30/2025 at 8:00 a.m., an interview with S3 LPN revealed that both Resident #2 and Resident #4 exhibited aggressive behaviors. S3 LPN confirmed that Resident #4's threats towards resident #2 were communicated to S2 DON on 09/21/2025. On 09/30/2025 at 11:05 a.m., an interview with S2 DON revealed she was made aware on 09/21/2025 that Resident #4 had made verbal threats of physical harm toward Resident #2. S2 DON stated she went to the residents' room and observed Resident #2 lying on a mat on the floor hollering and cursing, but Resident #4 was not present at that time. S2 DON confirmed the primary care provider or nurse practitioner was not notified after she was made aware of the threats and that no new orders were obtained. On 09/30/2025 at 11:45 a.m., an interview with S1 Administrator revealed he was unaware of any behavioral issues or threats between Resident #2 and Resident #4 prior to the 09/21/2025 altercation and confirmed that S2 DON should have made him aware of the threats, but had not.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Legacy Nursing at St.

Christina

122 Hillsdale Drive Pineville, LA 71360

SUMMARY STATEMENT OF DEFICIENCIES