Roseview Nursing and Rehab: Care Plan Failure Drops Resident - LA
The incident happened on July 25, 2025. Federal inspectors documented it during a complaint inspection completed August 13.
The resident, identified in inspection records only as Resident #1, had been at Roseview since March 2024. His diagnoses included ataxia following a brain hemorrhage, essential tremor, muscle wasting in both legs, weakness, contracture, and aphasia — a condition that left him rarely or never able to make himself understood. He was entirely dependent on staff for eating, bathing, toileting, and oral hygiene. He could not roll himself in bed. He was always incontinent.
His care plan was unambiguous: two-person assist required for all activities of daily living and transfers. High fall risk. Bedbound. And above his bed, visible to anyone who walked into the room, a sign said the same thing.
The aide, identified as S4 CNA, later gave a written statement describing what happened. "I went to Resident #1's room to check and see was he wet," she wrote. "He was soaked in pee and bowel movement. I looked on the hall to see if there were available aides. I didn't see any so I decided to change Resident #1."
She described pulling fresh linen, turning him to remake the bed, then reaching for a brief and pad. "Resident #1 moved a little and hit the floor. I didn't have any time to catch him."
A licensed practical nurse, S3 LPN, was called to the room. She found Resident #1 lying flat, face-first on the floor, in the narrow space between the bed and the air conditioning unit along the wall.
The CNA supervisor, S5, said during an interview on August 13 that the aide was not unfamiliar with this resident. She knew him. She knew his care requirements. "S4 CNA had experience working with Resident #1 and knew Resident #1 was a two person assist with all ADL care," the supervisor told inspectors, "and should have asked for assistance before providing ADL care to Resident #1."
The Director of Nursing, S2 DON, confirmed during a separate interview on August 12 that the sign above the bed was there. She confirmed the aide worked alone anyway. "S4 CNA did not follow the wall care plan on 07/25/2025 and use one person assist and should have used two person assist during ADL care for Resident #1."
The inspection report rates the harm level as minimal harm or potential for actual harm — the lower end of the federal scale. What the report does not detail is the extent of any injuries Resident #1 sustained when he landed face-first on the floor, a man who cannot communicate and cannot move himself.
The aide's statement offers the clearest window into what went wrong and why. She saw the problem. She looked for help. She found none visible. And she made a decision that the care plan, the supervisor, and the sign above the bed all said not to make. Whether she called for help before entering the room, whether she waited, whether anyone was actually unavailable or simply out of her sightline down the hall, the inspection report does not say.
What it says is that a man who could not roll himself, could not ask for help, and could not break his own fall was turned by one person in a bed he was never supposed to be turned in alone.
The sign was still there when inspectors arrived.
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.
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 22, 2026 · Our methodology
Roseview Nursing and Rehabilitation Center in Shreveport, LA was cited for violations during a health inspection on August 13, 2025.
The incident happened on July 25, 2025.
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.