Ridgeview Health Services: Fall Safety Failures - AL
The resident, identified in inspection records only as Resident 16, lives at Ridgeview Health Services, Inc., a nursing home at 907 11th Street in Jasper. The resident carries diagnoses of dementia with agitation and a personal history of transient ischemic attack. On the evening of December 7, 2024, staff found Resident 16 on the floor.
The response that night was immediate and specific. The nurse on duty ordered fall mats placed on both sides of the bed. Four days later, a second intervention was added: the bed was to be kept in its lowest position whenever Resident 16 was in it. Both measures were written into the resident's care plan and resident profile. Staff knew about them. The unit manager knew about them. The plan was clear.
What happened next was not.
On August 5, 2025, at 3:58 in the afternoon, a surveyor walked into Resident 16's room. There was one fall mat, on the left side of the bed. The right side had nothing. The bed was not lowered.
The surveyor came back the next morning at 8:27. One mat, left side only. Bed not lowered.
That same afternoon, at 3:22, the surveyor looked again. One mat. Left side. Bed up.
The following morning, August 7, at 7:52 a.m., the same thing. One mat on the left. Bed not in the lowered position.
Four observations across three days. The same two failures every time.
The registered nurse who had been assigned to Resident 16 on the night of the December fall was reached by phone on August 7. She said the plan had been for mats on both sides of the bed and for the bed to be lowered when Resident 16 was in it. The certified nursing assistant who had also worked that evening said the same: the bed was supposed to be kept in its lowest position.
CNA #9, who was assigned to Resident 16 on the morning of August 8, was told by the surveyor what had been observed over the previous three days. Asked whether it would be important to make sure fall interventions were actually in place, the aide said yes — so the resident would not fall and hurt themselves.
The unit manager for Resident 16's hall, a registered nurse identified as RN #10, was interviewed that same afternoon. She walked through exactly how the system was supposed to work: fall interventions are listed in the resident's profile, CNAs are responsible for checking that profile, and whatever is listed should be in place. She confirmed that the mats and the lowered bed should have been in place on August 5, August 6, and August 7. When asked why that mattered, she said: to avoid injury.
Nobody disputed the facts. Nobody said the care plan was unclear, or that the profile was hard to find, or that there had been some confusion about what the interventions required. The plan was written down. The staff knew it. The unit manager knew it. And for at least three days during a federal inspection — when a facility is typically at its most attentive — the right side of Resident 16's bed had no mat on the floor, and the bed sat at a height that made a fall more dangerous.
The inspection was conducted on August 8, 2025. Surveyors cited the deficiency under the federal requirement that facilities take reasonable steps to prevent accidents, classifying it as minimal harm or potential for actual harm. Resident 16 was one of four residents sampled for accident-related care during the survey.
Dementia with agitation is not a static condition. Residents with that diagnosis can move unexpectedly, rise from bed without warning, and lose their balance without any awareness of the danger. A fall mat on one side of a bed addresses one direction of a fall. A bed that isn't lowered means a greater distance to the floor. These are not complicated interventions. They require no equipment beyond what was already ordered, no additional staff, no new training. They require someone to put a mat on the right side of the bed and press a button.
That did not happen. For three days, while the surveyor was in the building, it did not happen.
Resident 16 did not fall during those three days. That is the only thing the record shows went right.
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.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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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 Resident 16, lives at Ridgeview Health Services, Inc., a nursing home at 907 11th Street in Jasper.
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.