Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Roseview Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with bilateral BKA, hemiplegia, and wheelchair dependence, care planned as high risk for falls, was transported in the facility van with the wheelchair floor straps secured but without the required chest and lap safety belts across the body. During the trip, the CNA van driver braked and the resident fell out of the wheelchair onto the van floor. Staff pulled over, used the ramp, and repositioned the resident back into the wheelchair and continued to the appointment without securing the chest or lap belt. The facility was not notified at the time of the fall, no nurse assessment was performed on the resident upon return, the nurse was unaware of the incident, and no accident/incident report or incident log entry was completed, despite facility policies requiring immediate nurse evaluation, physician notification, and written documentation for accidents and falls.
A deficiency occurred when staff inaccurately completed a required daily van safety checklist during a resident transport. Facility policy required documentation of correct use of the shoulder and lap belt and identification of any unsafe conditions for every transport. On the relevant date, the CNA/van driver marked that the shoulder and lap belt were correctly secured and that there were no unsafe conditions, even though the chest strap was not used during the transport. In subsequent interviews, both the Administrator and the CNA/van driver acknowledged that the checklist entry was inaccurate and that the item regarding correct shoulder and lap belt use should have been marked "no."
Medications were left at the bedside for two residents without orders or assessments for self-administration. One resident had fluticasone nasal spray on the bedside table, and another had docusate sodium at the bedside; in both cases, the ADON confirmed there was no self-administration order or assessment.
Improper Storage of Respiratory Equipment: The facility failed to store respiratory equipment properly for two residents receiving respiratory services. One resident with COPD and moderately impaired cognition had a nebulizer mask and tubing left on a fridge without a plastic bag, and another resident with OSA had a bi-pap mask left on a bedside table without a plastic bag and without a date. An ADON, an LPN, and the DON confirmed the improper storage.
A resident with dysphagia and moderately impaired cognition was ordered a mechanical soft diet with ground meats, but was observed being served a meal that was not prepared to that texture. The DON, SLP, and Dietary Manager confirmed the resident should have received a mechanical soft diet and that the chicken and sausage were chopped instead of ground.
Glucometer Quality Control Logs showed multiple control readings for 4 glucometers were documented as within range even though the recorded values were outside the acceptable limits, with some entries illegible or overwritten and no comments explaining the results. The DON confirmed the out-of-range and unclear entries, and one glucometer log also lacked lot numbers, expiration dates, and acceptable ranges for the control solutions.
A facility failed to inform and provide written information about the right to formulate an advance directive for 3 residents reviewed. Their Advanced Directives Checklists were incomplete and did not show whether the residents or responsible parties were given this information, and an RN confirmed the forms were incomplete.
Failure to notify a resident’s RP of a fall. A resident had an unwitnessed fall in the room, was found on the floor by a CNA, and had no noted injuries; hospice was notified, but the nurse’s notes and incident report did not show that the RP was informed. The RP stated the facility never notified her and said she was told only hospice had to be notified. The DON confirmed hospice did not notify the RP and agreed the facility was responsible for the notification.
The facility failed to notify the State LTC Ombudsman in writing of a resident’s emergency hospital transfer and failed to give the resident and RP written notice of the bed-hold policy duration at the time of transfer. The transfer log did not show the resident was entered for the hospital transfer, and the Corporate Nurse stated the Ombudsman was not notified and the bed-hold policy was not completed.
A resident with a Foley catheter was observed with the collection bag hanging from the bed frame and resting on the floor, with a puddle of malodorous urine on the floor nearby. An LPN and a restorative aide both stated the bag should not have been on the floor. The resident had neurogenic bladder, UTI, and cognitive communication deficit, and the care plan included catheter care and keeping the drainage tubing kink free.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident who was bedbound and required total care for all ADLs, including a two-person assist for transfers, was provided incontinent care by a single CNA. The CNA, despite being aware of the care plan and posted signage, attempted to turn the resident alone, resulting in the resident falling from the bed. Supervisory staff confirmed the care plan was not followed.
A resident, who was cognitively intact and had multiple medical conditions, experienced verbal abuse from a CNA. The CNA made inappropriate comments about providing care and used profanity when the resident fell. Video footage confirmed the CNA's behavior, and the DON acknowledged a violation of company policy.
A resident with multiple medical conditions fell while attempting to get into her wheelchair, and the facility failed to conduct a full assessment before moving her. The LPN and CNAs moved the resident without assessing her condition, contrary to facility policy. The resident later required hospital treatment for a right femur fracture.
Failure to Secure Resident During Van Transport and to Assess and Document Post-Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was properly secured during facility van transport, to assess the resident after a fall in the van, and to promptly report and document the incident. The resident had multiple significant diagnoses, including type 2 diabetes mellitus with hyperglycemia, hemiplegia and hemiparesis following cerebral infarction, glaucoma, bilateral below-knee amputations, and muscle wasting and atrophy, and used a wheelchair for mobility. The resident’s care plan identified a high risk for falls related to being a bilateral amputee and wheelchair-bound. Facility policy for accidents and falls required that residents not be moved until evaluated by a licensed nurse, that the nurse in charge be notified, that a thorough head-to-toe assessment be completed, that the physician be notified for follow-up orders, and that an accident/incident report and appropriate documentation be completed by the end of the shift. On the date of the incident, the resident was being transported by facility van to a medical appointment with a CNA who was also the van driver, another CNA, and a complainant present. Multiple interviews indicated that while the wheelchair was secured at the front and back on the van floor, the chest strap and lap safety belt that hook together across the resident were not in place. The resident, the complainant, and the accompanying CNA reported that the chest strap did not work or was not snapped in and attached, and that they proceeded with transport without the chest or lap strap across the resident. During transport, the van driver applied the brakes at a light, and the resident came out of the wheelchair and fell to the floor of the van, ending up on the floor facing the back of the van. Staff then pulled the van over, opened the back, used the ramp, and repositioned the resident back into the wheelchair, which took an extended period of time, and then continued on to the scheduled appointment without the chest strap or lap belt in place. Following the incident, the facility did not follow its own accident and fall policies. The van driver did not call the facility at the time of the fall so that a nurse could assess the resident before he was moved or before proceeding to the appointment. The resident’s nurse reported not being informed of the fall and therefore did not complete an assessment. The incident was not entered on the facility’s incident log, and no accident/incident report was completed by the end of the shift or thereafter. The DON, administrator, and corporate nurse later acknowledged that the chest and lap safety belts were not used, that the van driver should have called the facility and that the resident should have been assessed for injuries, and that an incident report and documentation should have been completed. The resident reported that no one checked on him or asked if he was okay upon his return to the facility, and the complainant reported the resident had bruises on his residual limbs after the fall.
Inaccurate Documentation on Van Safety Checklist During Resident Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate documentation on the daily van safety checklist for a resident transported by the facility van. The facility’s policy required the daily van safety checklist to be used for every transport and to document whether the shoulder and lap seat belt was secured correctly, whether seatbelts and wheelchair straps were re-checked after initial strapping, and whether any unsafe conditions existed. Review of the checklist for 01/08/2026 showed that the van driver/CNA documented “yes” to the question about correct shoulder and lap belt use and indicated no unsafe conditions. However, during an interview, the Administrator stated that staff on the van did not use the strap across the resident’s chest during the transport on that date and acknowledged that the driver’s documentation was inaccurate. In a separate interview, the van driver/CNA confirmed that the checklist should have been marked “no” for the question about correct shoulder and lap belt use at the time of the resident’s transport, demonstrating that the record did not accurately reflect the actual safety measures used during the transport. No additional medical history or clinical condition of the resident at the time of the deficiency is provided in the report.
Medications Left at Bedside Without Self-Administration Orders
Penalty
Summary
The facility failed to provide services that met professional standards of quality for 2 residents related to accident hazards and supervision because medications were left at the bedside without orders or assessments for self-administration. The facility's self-administration policy stated that the interdisciplinary team must assess a resident's overall ability to safely administer medications before the resident exercises that right. One resident had diagnoses including allergic rhinitis and chronic systolic congestive heart failure, and a BIMS score of 15 indicating no cognitive impairment. The resident had an order for fluticasone propionate nasal spray, but the record did not show an order for self-administration or an assessment for self-administration. Surveyors observed the fluticasone nasal spray on the bedside table, and the ADON confirmed it should not have been left there. Another resident had diagnoses including hypertensive urgency, psychotic disorder with delusions due to known physiological condition, and constipation, with a BIMS score of 14 indicating no cognitive impairment. The record did not show an order for docusate sodium or an assessment for self-administration, yet surveyors observed a bottle of docusate sodium on the bedside table, and the ADON confirmed it should not have been at the bedside.
Improper Storage of Respiratory Equipment
Penalty
Summary
Safe and appropriate respiratory care was not provided for 2 residents reviewed for respiratory services because the facility failed to ensure proper storage of respiratory equipment. The facility’s oxygen administration policy stated that humidifier bottles, cannulas, and oxygen tubing are to be changed at least weekly and dated, and that when not in use, a cannula or mask should be placed in a plastic bag. Resident #7 had diagnoses including heart failure, paroxysmal atrial fibrillation, shortness of breath, and COPD with acute exacerbation, and had an order for ipratropium-albuterol inhalation solution via handheld nebulizer as needed for SOB. The resident’s BIMS score was 9, indicating moderately impaired cognition. On multiple observations, the resident’s nebulizer was on top of a personal fridge with the mask and tubing not placed in a plastic bag. An ADON later confirmed the nebulizer mask and tubing were not stored properly and should have been stored and labeled in a plastic bag when not in use. Resident #9 had diagnoses including obstructive sleep apnea and chronic diastolic heart failure and had an order to apply a bi-pap machine at bedtime. On multiple observations, the bi-pap machine was on the bedside table and the face mask was not in a plastic bag and was undated. An LPN and the DON both confirmed the bi-pap mask was not in a plastic bag and was not dated.
Failure to Provide Ordered Mechanical Soft Diet
Penalty
Summary
The facility failed to ensure that Resident #7 received a mechanically soft diet as ordered by the physician. Resident #7 was admitted with a diagnosis of dysphagia (oropharyngeal phase) and had physician orders for a regular no-salt-on-tray diet with mechanical soft texture and regular/thin consistency. The resident’s quarterly MDS documented a BIMS score of 9, indicating moderately impaired cognition, and noted that the resident held food in the mouth or cheeks, coughed or choked during meals or when swallowing medications, and complained of difficulty or pain when swallowing. The care plan also identified potential oral pain, oral irritation, and difficulty chewing related to dentures, with interventions for a no-salt-on-tray mechanical soft diet. During lunch observation, Resident #7 was served chicken and sausage gumbo with rice, lettuce and tomato salad, garlic bread, and peach cobbler. The DON reviewed the meal ticket and confirmed the resident should have been served a mechanical soft diet. The SLP stated the resident had dysphagia with swallowing and chewing issues and should be on a mechanical soft diet with ground meats. The Dietary Manager confirmed the resident’s diet was mechanical soft with ground meats and that the chicken and sausage had been chopped instead of ground, meaning the meal was not prepared correctly for the ordered diet.
Glucometer Quality Control Logs Contained Out-of-Range and Illegible Entries
Penalty
Summary
The facility failed to ensure 4 of 4 glucometers used for residents with orders for blood glucose monitoring were maintained in safe operating condition. The facility’s Glucometer Information Sheet stated that the EvenCare 2 glucometer was in use, that control testing was to be completed at least daily, and that any out-of-range control reading would not be used for resident testing until the glucometer was repaired or repeat control tests were within normal limits. The Director of Nursing reported the facility had 29 residents who required blood glucose monitoring with the facility’s glucometer. Review of the November 2025 and December 2025 Glucometer Quality Control Logs showed multiple control results documented as within range when the recorded values were outside the acceptable ranges for glucometers #1, #2, #3, and #4. Some entries were illegible or overwritten, including a high control reading that appeared to be 232 and another recorded as 1, and several out-of-range readings had no comments explaining how they were handled. For glucometer #1 in November 2025, the log also failed to include lot numbers, expiration dates, and acceptable ranges for the low and high control solutions. During interview, the DON reviewed the logs and confirmed the illegible control values, out-of-range control values without comments, and the missing documentation for glucometer #1.
Incomplete Advance Directive Information Documentation
Penalty
Summary
The facility failed to inform and provide written information to residents or their representatives concerning the right to formulate an advance directive for 3 of 32 residents reviewed for advance directives. Resident #30 was admitted on 05/22/2024, and the Advanced Directives Checklist signed that same day was incomplete and did not indicate whether the resident or responsible parties were given information on formulating an advance directive. Resident #45 was admitted on 05/02/2024, and the Advanced Directives Checklist signed on that date was also incomplete and failed to show whether the resident or responsible parties were given this information. Resident #76 had an incomplete Advanced Directives Checklist signed on 06/27/2024 that likewise did not indicate whether the resident or responsible parties were informed about formulating an advance directive. During interview, the Corporate Nurse reviewed the three checklists and confirmed they were incomplete and did not indicate whether the information had been provided.
Failure to Notify Resident Representative of Fall
Penalty
Summary
The facility failed to inform a resident’s responsible party/representative of a change in condition for one resident reviewed for falls. The facility’s Resident and Family Notification Guidelines stated that notification of the resident and resident representative of changes in condition is the primary responsibility of the nurse assigned to the resident, and that documentation should include the name of the resident representative spoken with. The guidelines also listed any accident, injury, or incident report as situations requiring notification and documentation. Resident #35 had an unwitnessed fall in the resident’s room on 12/01/2025 and was found on the floor by a CNA between the bed and the air conditioning unit on the left side of the bed. The resident reported that the sheet was wet and that the resident was trying to move it. No injuries were noted, the resident was alert and oriented, and hospice was notified. Review of the incident report and nurse’s notes did not show that the resident’s RP was notified. During interview, the RP stated the facility never notified her of the falls and said she was told the facility only had to notify hospice. The record identified the RP as a friend and also listed a family representative/financial POA. The DON stated hospice would notify the RP if a resident had a fall or change in condition, but confirmed hospice did not notify the RP and agreed that notifying the RP was ultimately the facility’s responsibility.
Failure to Notify Ombudsman and Provide Bed-Hold Notice
Penalty
Summary
The facility failed to notify the State's Long-Term Care Ombudsman in writing of an emergency discharge to the hospital for Resident #23 and failed to provide the resident and responsible party written notice specifying the duration of the bed-hold policy at the time of transfer. Review of the Emergency Transfer Log for October 2025 did not show Resident #23 was entered on the log for the 10/21/2025 hospital transfer, and further review did not reveal documentation that the resident or responsible party received bed-hold policy information at the time of discharge. The facility's Emergency Transfer Log stated that the document would be emailed to the Office of the State Ombudsman by the 15th of each month and would include the location of transfer, written notification date to the resident, transfer date, date of return to the facility, and reason for transfer. During interview, the Corporate Nurse stated the Office of State Ombudsman was not notified of the emergency transfer and that a bed-hold policy was not completed.
Foley Catheter Bag Left on Floor
Penalty
Summary
The facility failed to follow recognized infection control practices for a resident with an indwelling Foley catheter when the catheter collection bag was observed hanging from the bed frame and laying on the floor. During the observation, a puddle of malodorous urine was also seen on the floor along the foot of the bed. Staff interviewed at the time, including a restorative aide and an LPN, stated that the Foley catheter bag should not have been on the floor. Resident #23 had diagnoses including neurogenic bladder, urinary tract infection, and cognitive communication deficit. The resident had a current physician order for Macrobid 100 mg at bedtime related to urinary tract infection, and the care plan identified the Foley catheter for neurogenic bladder with interventions for catheter care, monitoring urine, changing the catheter as ordered, and ensuring the drainage tubing remained kink free. The facility's catheter management policy stated that the bag or tubing should never be allowed to touch the floor.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Follow Two-Person Assist Care Plan During ADL Care
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan, which required a two-person assist for all activities of daily living (ADLs) and transfers. The resident, who was bedbound and dependent on staff for all ADLs due to multiple diagnoses including ataxia, muscle wasting, contractures, and aphasia, was found to be always incontinent and required total care. The care plan and signage above the resident's bed clearly indicated the need for two-person assistance. Despite this, a CNA provided incontinent care alone after not finding another available aide. While changing the resident, the CNA attempted to turn the resident without assistance, resulting in the resident rolling off the bed and falling to the floor. The incident was confirmed by nurse's notes and interviews with supervisory staff, who acknowledged that the CNA was aware of the two-person assist requirement but did not follow the established care plan.
Verbal Abuse Incident by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by a staff member. The incident involved a resident who was cognitively intact, as indicated by a BIMS score of 15, and had multiple medical conditions including ESRD, COPD, and anxiety disorder. The resident reported that a CNA entered her room and made an inappropriate comment about providing incontinent care. Additionally, the resident's responsible party reported hearing the CNA use profanity and dismissive language when the resident fell and called for help. Video footage confirmed the presence of the CNA in the resident's room and captured the CNA using curse words in the hallway. The CNA admitted to confronting the resident about allegedly lying about being on the floor. The DON confirmed that the CNA's language violated company policy. The incident highlights a failure in maintaining a respectful and abuse-free environment for residents.
Failure to Conduct Proper Assessment After Resident Fall
Penalty
Summary
The provider failed to ensure services met professional standards of quality by not completing a full head-to-toe assessment with vital signs after a resident fall. The facility's policy required that a licensed nurse assess the resident's condition before moving them, but this was not followed. The incident involved a resident with multiple medical conditions, including ESRD, COPD, and a history of falls, who fell while trying to get into her wheelchair. The resident was found on the floor by a CNA, and the wheelchair was noted to be unlocked. The LPN on duty, upon hearing the resident scream, called for CNAs to assist but did not perform the required assessment before the resident was moved. The CNAs, with the LPN holding the wheelchair steady, moved the resident into the wheelchair without a prior assessment. The resident later complained of hip pain, and subsequent imaging revealed a right femur fracture, necessitating hospital transfer and surgical intervention. Interviews with staff confirmed that the facility's protocol for fall incidents was not followed. The LPN and CNAs involved acknowledged that an assessment should have been conducted before moving the resident. The Director of Nursing also verified that a full assessment was required before moving any resident who had fallen. This oversight led to a delay in identifying the resident's injury and providing appropriate care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Shreveport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shreveport Manor Skilled Nursing & Rehabilitation | 0.1 mi | ★★★★★ | 8 | 0 |
| Progressive Care Center | 0.3 mi | ★★★★★ | 3 | 0 |
| Willis-knighton Extended Care Center | 0.3 mi | ★★★★★ | 0 | 0 |
| Claiborne Healthcare Center | 0.7 mi | ★★★★★ | 7 | 1 |
| Magnolia Manor Nursing And Rehab Ctr, Llc | 0.8 mi | ★★★★★ | 6 | 0 |
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