Pilgrim Manor: Wrong Transfer Method Broke Resident's Arm - LA
The incident happened on July 14, 2025, at Pilgrim Manor Skilled Nursing and Rehabilitation. The agency CNA, identified in inspection records as S6, arrived late that morning because she had to wait for the agency to arrange coverage after a staff call-in. When she got there, she was handed access to the CNA charting record and her list of assigned residents.
She didn't know the woman required a Hoyer lift. She said she didn't know how to look up a resident's transfer abilities in the system. Nobody told her before she walked into that room.
The resident, identified only as Resident 1, told the CNA she had hit her arm on the wheelchair during the transfer and complained of pain. An x-ray confirmed a fracture.
The wound care nurse who spoke with inspectors on September 3 was direct about what the standard was. Resident 1 "could not do anything on her own," the nurse said, and required a Hoyer lift for every transfer. There should have been a sign posted above the resident's door saying so. Whether that sign was there on July 14 is not addressed in the inspection report.
The assistant director of nursing told inspectors she had been called to accompany the director of nursing when the incident occurred. She said she was told Resident 1 had been transferred using a "lift and pivot method." She said she did not recall the resident's transfer requirements without reviewing the record.
The agency CNA's work history at the facility tells a more complicated story than a one-time unfamiliar worker walking into an unfamiliar building. According to the facility's own records, reviewed by the quality improvement nurse during the inspection, the CNA had first worked at Pilgrim Manor on April 14, 2025. She then worked there on July 1, July 5, July 6, July 8, and July 13, the day before the fracture. Six shifts in the weeks leading up to the injury. The quality improvement nurse confirmed the CNA's charting entries for those dates showed what the records described as proficient use of the resident care guides.
She knew how to chart. She did not know, she said, how to look up how a resident needed to be moved.
After Resident 1's arm broke, the CNA was given in-service training on how to find transfer information in the system. The inspection report does not indicate whether any review was conducted of her prior shifts or whether other residents she transferred during those six visits were assessed for harm.
The inspection was conducted on September 3, 2025, in response to a complaint, and inspectors classified the violation as causing actual harm to a small number of residents.
What the record shows is a woman who could not move on her own, whose transfer requirements were known to the nursing staff, whose room the inspection suggests should have been marked with a warning, and who ended up with a broken bone because the person assigned to move her that morning had never been shown how to find out what she needed. The CNA said she learned how to check after the incident. Resident 1 learned what happens when nobody checks before.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pilgrim Manor Skilled Nursing and Rehabilitation from 2025-09-03 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Pilgrim Manor Skilled Nursing and Rehabilitation in Bossier City, LA was cited for violations during a health inspection on September 3, 2025.
The incident happened on July 14, 2025, at Pilgrim Manor Skilled Nursing and Rehabilitation.
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.