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
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: August 5, 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.