Pilgrim Manor: Unsafe Transfer Violation - Bossier City, LA
The resident, identified in inspection records as Resident F3, was classified as a total lift patient. That designation meant staff could not move her from bed to wheelchair without a Hoyer lift and a second person present. The classification was not new or informal. The facility's own list, updated as recently as October 14, 2025, still showed Resident F3 as a Hoyer lift resident.
The agency CNA, identified as SF4Agency CNA, signed a facility orientation acknowledgment on September 8, 2025. That document told her explicitly that the resident plan of care could not be changed without reassessment by a nurse or management, and that her responsibility as agency staff was to provide care consistent with each resident's needs. She signed it.
She transferred Resident F3 anyway. When inspectors later asked about the Hoyer lift pad found in the resident's room, she explained her method herself.
The Director of Rehabilitation told inspectors on October 28 that she had personally assisted nursing staff with transfer assessments and that the Hoyer lift recommendation for Resident F3 had not changed. She acknowledged that CNAs were required to use the lift with two-person assistance for any resident classified as a total lift. The corporate nurse said the same thing in a separate interview the same afternoon: Resident F3 required a Hoyer lift with two-person assist, and the transfer should not have happened the way it did.
The Centers for Medicare and Medicaid Services cited the facility under Tag F0600, which covers abuse, neglect, and exploitation. CMS rated the level of harm as minimal harm or potential for actual harm, affecting a few residents.
That rating reflects the regulatory floor, not the physical reality of what a manual transfer means for a person designated as a total lift patient. Residents receive that classification because they cannot bear weight or assist meaningfully with movement. Transferring one person without mechanical support and without a second set of hands creates the conditions for a fall, a fracture, or a soft tissue injury. The inspection record does not document that Resident F3 was physically harmed. It does not document that she was not.
What the record does show is that the aide knew the requirement, had signed paperwork confirming she understood it, found the Hoyer lift pad sitting in the resident's room, and moved her anyway.
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.
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: July 27, 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 resident, identified in inspection records as Resident F3, was classified as a total lift patient.
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.