Roseview Nursing And Rehabilitation Center
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
attended in-services on resident wall care plans and knew to look at the sign on the wall to see if the resident was a one or two person assist. S14 CNA understood to never attempt to move or transfer a resident alone if the resident was a two person assist.During an interview on 08/13/2025 at 8:32 a.m. S7 CNA reported she attended the in-service on Bed Mobility and turning schedule. S7 CNA further reported
the meeting included how important it was to use two person assist if the wall care plan indicated two person assist. If there was not another CNA to help, she would call the nurse or a supervisor to help and never attempt two person assist care alone. During an interview on 08/13/2025 at 8:33 a.m. S8 CNA reported he attended the in-service regarding wall care plans and the importance of following the wall care plans. S8 CNA further reported he checked the wall care plans upon entering a room and checked if the resident was a one or two person assist. If the resident was a two person assist, S8 CNA reported he would ask for assistance and never attempt to move or change a resident without another person to assist. During
an interview on 08/13/2025 at 8:39 a.m. S9 LPN reported she attended the in-service on bed mobility and wall care plans which included to check residents wall care plans located above the resident's bed. S9 LPN reported she would assist CNAs when needed for residents requiring two person assist patient care. During
an interview on 08/13/2025 at 8:59 a.m. S2 DON reported S4 CNA was suspended right after the incident.
S4 CNA stayed for the in-service on wall care plans and left after that. S2 DON reported S4 CNA did not care for any residents after the incident with Resident #1. S2 DON further reported S4 CNA was called to
the facility the next day to sign papers on termination for not following the company policy.
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
08/13/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Roseview Nursing and Rehabilitation Center
3405 Mansfield Road Shreveport, LA 71103
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-Tag F0656
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview, the facility failed to follow a resident's plan of care for 1 (#1) of 3 (#1, #2, #3) sampled residents. Findings:Review of Resident #1's medical record revealed an initial admission date of 03/27/2024 with diagnoses, which included in part, ataxia following other non-traumatic intracranial hemorrhage, essential tremor, muscle wasting and atrophy of left lower leg and right lower leg, weakness, contracture of muscle, multiple sites and aphasia. Review of Resident #1's Quarterly MDS (Minimum Data Set) assessment dated [DATE REDACTED] indicated BIMS (Brief Interview of Mental Status) could not be completed due to resident was rarely/never understood. Further review of the Quarterly MDS assessment revealed Resident #1 had upper and lower extremity impairments to both sides, dependent with eating, oral hygiene, toileting hygiene, and shower/bathe self. Resident #1 was dependent for mobility in rolling left and right.
Resident #1 was always incontinent of bowel and bladder and dependent on staff for ADL (Activities of Daily Living) care. Review of Resident #1's comprehensive care plan revealed in part, Resident #1 was at high risk for fall related to neurocognitive disorder and required total care with bedbound status. Further
review of the comprehensive care plan revealed Resident #1 had an ADL deficit and required two person assist with all ADLs and transfers.Review of S4 CNAs (Certified Nursing Assistant) signed witness statement (undated) revealed: I went to Resident #1's room to check and see was he wet. 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. His bed was soaked with urine so I had to change, I grabbed my linen to put on his bed. 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.Review of Resident #1's nurse's notes dated 07/25/2025 at 11:44 a.m. revealed S3 LPN (Licensed Practical Nurse) was called to Resident #1's room. Upon entering the room, Resident #1 was lying flat and face first on the floor to the right side of the bed between the air unit and bed. S3 LPN was informed by S4 CNA that while she was performing incontinent care and went to turn Resident #1, Resident #1 rolled off the bed to the floor. During an
interview on 08/13/2025 at 1:20 p.m. S5 CNA Supervisor reported S4 CNA 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 to Resident #1. During an interview on 08/12/2025 at 11:18 a.m. S2 DON (Director of Nursing) confirmed there was a sign above Resident #1's bed notifying staff Resident #1 was a two person assist with all ADLs. S2 DON confirmed 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.
Event ID:
Facility ID:
If continuation sheet
Roseview Nursing and Rehabilitation Center in Shreveport, LA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Shreveport, LA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Roseview Nursing and Rehabilitation Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.