Roseview Nursing And Rehabilitation Center
Roseview Nursing and Rehabilitation Center in Shreveport, LA — inspection on August 13, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
incident with Resident #1. S2 DON further reported S4 CNA was called to the facility the next day to
jeopardy to resident health or safety
195496 08/13/2025
Roseview Nursing and Rehabilitation Center 3405 Mansfield Road Shreveport, LA 71103
Review of Resident #1's Quarterly MDS (Minimum Data Set) assessment dated [DATE] 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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.