Pilgrim Manor Skilled Nursing And Rehabilitation

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Hoyer lift pad in her room and stated so I just transferred her (Resident #F3) the old school way. Review of S4Agency CNA's personnel record revealed an Agency CNA Facility Orientation acknowledgement dated and signed by SF4Agency CNA on 09/08/2025. Further review of SF4Agency CNA's Agency CNA Facility Orientation acknowledgement revealed the following responsibilities in part: - Locate Care Guide Care Guide and ____ in [kiosk]- Resident's plan of care is made by the team. The plan of care cannot be changed without or until the nurse or management has reassessed the resident. *As an agency staff member, I understand and acknowledge, it is my responsibility to provide quality of care consistent to the resident's needs. Any questions or concerns should be reported to the DON (Director of Nursing) or Administration. During an interview on 10/28/2025 at 3:00 p.m., SF6DOR (Director of Rehabilitation) reported she had assisted nursing staff with resident transfer assessments and recommendations for the need of Hoyer lifts. SF6DOR further reported the transfer recommendation for Resident #F3 remained as a Hoyer lift resident as indicated on the most recent 10/14/2025 facility list. SF6DOR acknowledged Resident #F3 had a status of total lift and CNAs should use a Hoyer lift with 2 staff assistance for total lift residents.

During an interview on 10/28/2025 at 3:30 p.m., SF1Corporate Nurse acknowledged Resident #F3 required

a Hoyer lift with 2 person assist for transfers and should have been transferred from the bed to the wheelchair with a Hoyer lift by SF4Agency CNA. [KH1]

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/03/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pilgrim Manor Skilled Nursing and Rehabilitation

1524 Doctors Drive Bossier City, LA 71111

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

trained on how to locate things in a resident's CNA charting including transfer abilities. S1 Quality Improvement Nurse and S2 Quality Improvement Nurse confirmed the agency CNAs sign on the Agency Facility Orientation sheet indicating they were oriented to the facility CNA charting system.During an

interview on 09/02/2025 at 2:20 p.m. S5 ADON confirmed new staff and agency CNA staff were oriented to

the facility, given access to the CNA charting record, and trained on how to locate things in a resident's CNA charting including transfer abilities prior to working. S5 ADON confirmed the agency CNAs sign on the Agency Facility Orientation sheet indicating they were oriented to the facility CNA charting system. S5 ADON reported she had scheduled staff for Resident #1's hall. S5 ADON reported on 07/14/2025 S6 agency CNA arrived late to the facility because she had to call the agency to cover staff due to a late call in.

S5 ADON reported she was called to go with S3 DON when the incident with Resident #1 occurred on 07/14/2025. S5 ADON reported she was told Resident #1 was transferred using a lift and pivot method. S5 ADON reported she did not recall Resident #1's transfer abilities without reviewing Resident #1's record.During an interview on 09/03/2025 at 10:15 a.m. S14 RN (Registered Nurse)/Wound Care Nurse reported Resident #1 could not do anything on her own and required the Hoyer lift for transfers. S14 RN/Wound Care Nurse reported there should have been a sign over Resident #1's door indicating she required a Hoyer lift for transfers.During an interview on 09/03/2025 at 11:00 a.m. S6 agency CNA reported

on 07/14/2025 she came late and was given access to the CNA charting record and her assigned residents. S6 agency CNA reported she transferred Resident #1 with a stand and pivot method and Resident #1 told her she hit her arm on the wheelchair and complained of pain. S6 agency CNA reported

she notified the nurse and DON and they assessed Resident #1, an x-ray was done, and Resident #1 had a fracture. S6 agency CNA reported she did not know Resident #1 was to be transferred with a Hoyer lift until

after the incident. S6 agency CNA reported she did not know how to look up a resident's transfer abilities until after the incident. When asked if she had worked at the facility before S6 agency CNA reported she had worked at the facility once before that date and had not come back until recently. S6 agency CNA reported she was in-serviced regarding obtaining information regarding proper transfer after the incident with Resident #1.During an interview on 09/03/2025 at 12:30 p.m. S2 Quality Improvement Nurse reviewed S6 agency CNA's work history in the facility and reported S6 agency CNA first worked at the facility on 04/14/2025 and did not work again at the facility until 07/01/2025. S2 Quality Improvement Nurse confirmed S6 agency CNA had worked at the facility on 07/01/2025; 07/05/2025; 07/06/2025; 07/08/2025; 07/13/2025; and 07/14/2025 and confirmed documentation of S6 agency CNA's charting record entries for the dates worked in July 2025 which indicated proficient use by the CNA of resident's care guides.

Event ID:

Facility ID:

If continuation sheet