Roseview Nursing: Resident Falls During Solo Care - LA
The July 25 incident at Roseview Nursing and Rehabilitation Center involved a resident who required two-person assistance for all daily care activities due to severe physical and cognitive impairments. A sign above the patient's bed clearly notified staff of this requirement.
The resident had been admitted in March 2024 with multiple diagnoses including brain hemorrhage effects, essential tremor, muscle wasting in both legs, weakness, muscle contractures and aphasia. Medical assessments showed the patient was rarely understood when speaking and required complete assistance with eating, oral hygiene, toileting and bathing.
Care plans documented the resident as bedbound and at high risk for falls due to neurocognitive disorder. The patient was always incontinent of bowel and bladder and dependent on staff for all activities of daily living.
According to the nursing assistant's written statement, she went to check if the resident was wet and found him "soaked in pee and bowel movement." The bed was also soaked with urine.
"I looked on the hall to see if there were available aides," the assistant wrote. "I didn't see any so I decided to change Resident #1."
She gathered clean linens and began the process alone. "I turned him and put the linen on the bed. I grabbed my pamper and pad. Resident #1 moved a little and hit the floor. I didn't have any time to catch him."
A licensed practical nurse was called to the room at 11:44 a.m. and found the resident lying flat and face-first on the floor to the right side of the bed. The nursing assistant told the LPN that while performing incontinence care and turning the resident, the patient rolled off the bed.
The facility's Director of Nursing confirmed during an August 12 interview that the nursing assistant "did not follow the wall care plan" and should have used two-person assistance during care for this resident.
A CNA supervisor who was interviewed the following day said the nursing assistant "had experience working with Resident #1 and knew Resident #1 was a two person assist with all ADL care and should have asked for assistance before providing ADL care."
The resident's comprehensive care plan specifically noted the patient required "two person assist with all ADLs and transfers" due to ADL deficits and high fall risk. Medical records showed the resident was dependent for mobility when rolling left and right and required total care due to bedbound status.
Federal inspectors found the facility failed to follow the resident's plan of care during their August investigation. The violation was classified as causing minimal harm or potential for actual harm to few residents.
The nursing assistant's decision to proceed with solo care despite knowing the two-person requirement and seeing the posted warning sign above the bed represented a fundamental breakdown in following established safety protocols for this vulnerable resident.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Roseview Nursing and Rehabilitation Center from 2025-08-13 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Roseview Nursing and Rehabilitation Center
- Browse all LA nursing home inspections
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 14, 2026 · Our methodology
Roseview Nursing and Rehabilitation Center in Shreveport, LA was cited for violations during a health inspection on August 13, 2025.
A sign above the patient's bed clearly notified staff of this requirement.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at Roseview Nursing and Rehabilitation Center?
- A sign above the patient's bed clearly notified staff of this requirement.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in Shreveport, LA, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Roseview Nursing and Rehabilitation Center or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 195496.
- Has this facility had violations before?
- To check Roseview Nursing and Rehabilitation Center's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.