Ridgeview Health Services: Dementia Ward Wandering Failures - AL
The resident, identified in inspection records only as RI #151, lived on the facility's dementia unit. According to the care plan, the goals were specific: behaviors would not pose a danger to self or others, would not interfere with daily living activities, and RI #151 would be easily redirected. The interventions were equally direct, walking alongside the resident, sitting and talking, reminiscing, offering an activity.
Nobody could say whether any of that happened.
When inspectors asked the facility's social worker on August 7, 2025, whether those interventions were used the night RI #151 wandered into a neighboring resident's room, she said she did not know. When asked what staff should have done, she said they should have walked with RI #151 or provided redirection. When asked what could have been done to prevent the intrusion into RI #152's room, she said she did not see how it could have been prevented because RI #151 was very unpredictable.
That answer sat alongside a care plan that existed precisely because RI #151 was unpredictable.
The certified nursing assistant who responded to the incident, identified as CNA #12, told inspectors that RI #151 wandered into other residents' rooms constantly, climbed into other beds, and fought back when staff tried to redirect. The behaviors were difficult to manage, the CNA said. When asked whether the incident could have been prevented, CNA #12 said it could have, if someone had been with RI #151 around the clock.
The Director of Nursing confirmed the full picture of RI #151's documented behaviors during an interview on August 8, 2025: constant wandering, refusing care, spitting out medications, entering other residents' rooms, requiring redirection. The DON said the care plan targeted specific interventions for that particular resident for a reason, to help de-escalate potential issues before they developed. The DON also acknowledged that a resident wandering into another person's room could upset that person and violate their privacy.
The social worker said wandering was not uncommon on the dementia unit, and that staff routinely provided redirection. She described the interventions available, the walking, the conversation, the activities, as if they were standard practice. But when the question turned to that specific night, the answer was the same: she did not know.
After the incident, staff intervened, provided redirection, notified a supervisor, and RI #151 was transferred to a behavioral unit. The response, when it came, followed the outline of the care plan. What inspectors could not establish was whether anyone had tried to follow it before RI #151 walked into RI #152's room.
The inspection was conducted on August 8, 2025. CMS classified the deficiency as causing minimal harm or potential for actual harm, affecting a limited number of residents.
RI #152 was in that room when it happened.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ridgeview Health Services, Inc from 2025-08-08 including all violations, facility responses, and corrective action plans.
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.
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Last verified: November 3, 2026 · Our methodology
RIDGEVIEW HEALTH SERVICES, INC in JASPER, AL was cited for violations during a health inspection on August 8, 2025.
The resident, identified in inspection records only as RI #151, lived on the facility's dementia unit.
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.