Ridgeview Health Services, Inc

**Inspection Narrative - Tag 0600: Freedom from Abuse and Neglect**

During a comprehensive inspection of Ridgeview Health Services, Inc. conducted between the survey dates, the facility failed to ensure that all residents were free from abuse and neglect as required by 42 CFR 483.12. This deficiency was identified through a combination of resident interviews, staff observations, record reviews, and assessment of facility policies and procedures.

The investigation revealed that the facility's systems for preventing, identifying, and responding to potential abuse were inadequate. Specifically, the facility failed to conduct thorough screening of potential employees, including complete background checks and verification of references prior to hire. A review of personnel files for three newly hired nursing assistants showed incomplete documentation of the screening process, with missing criminal background check results and no evidence of contact with previous employers.

Additionally, staff interviews revealed inconsistent understanding of mandatory reporting requirements. When questioned about recognizing signs of abuse, two of five nursing assistants were unable to articulate the proper procedures for reporting suspected incidents. One staff member stated uncertainty about whether to report observations directly to administration or to the state hotline, demonstrating gaps in training effectiveness.

The facility's abuse prevention training records showed that four current employees had not received their annual in-service education on recognizing and reporting abuse within the past twelve months, as required by facility policy and regulatory standards. This lack of current training placed residents at increased risk of undetected or unreported abuse.

These systemic failures compromised the facility's ability to maintain a safe environment and protect vulnerable residents from potential abuse and neglect, constituting a violation of residents' fundamental rights.

**INSPECTION NARRATIVE - TAG 0684**

**Facility:** Ridgeview Health Services, Inc. **Deficiency:** Failure to Provide Appropriate Treatment and Care According to Orders, Resident Preferences and Goals **Severity Level:** G - Isolated incident with potential for more than minimal harm

During the survey conducted on the unit, the inspection team reviewed clinical records and observed care delivery practices for a sample of residents. The investigation revealed that staff failed to consistently implement physician orders and honor documented resident care preferences.

Specifically, Resident #42, an 81-year-old female with diabetes mellitus, had physician orders dated three weeks prior requiring blood glucose monitoring before each meal and at bedtime. Record review indicated that blood glucose checks were documented only twice daily during the seven-day period examined, missing approximately 50 percent of the ordered monitoring times. Additionally, this resident's care plan documented a preference for receiving insulin injections in the abdomen rather than the upper arms due to prior bruising and discomfort. Nursing documentation showed that on four separate occasions during the review period, insulin was administered to the upper arm contrary to the resident's documented preference.

The medication administration records for Resident #78, a 76-year-old male with hypertension, showed that ordered blood pressure medication was administered four hours late on multiple occasions without documentation of the reason for the delay or physician notification.

This failure to follow physician orders and honor resident preferences compromised the ability to effectively manage chronic conditions, increased the risk of complications such as uncontrolled blood glucose levels, and demonstrated a lack of person-centered care. Regulations require facilities to provide care and services according to each resident's comprehensive assessment and plan of care, following physician orders while respecting individual preferences and promoting dignity and autonomy.

Based on observations conducted during the inspection survey of Ridgeview Health Services, Inc., it was determined that the facility failed to ensure one or more areas were free from accident hazards and did not provide adequate supervision to prevent accidents, as required under 42 CFR 483.25(h).

During the survey on the afternoon of the inspection date, the surveyor observed multiple environmental hazards in common areas and resident rooms that posed significant fall and injury risks. In the second-floor hallway near the rehabilitation therapy room, a housekeeping cart was left unattended with cleaning supplies and wet floor equipment partially obstructing the walkway. The cart was positioned in the primary traffic path used by residents ambulating with walkers and wheelchairs. No wet floor signage was present, and the area showed evidence of water spillage on the flooring surface.

Additionally, in Room 218, occupied by two residents with documented histories of falls, the call light cord was observed wrapped around the bed rail and positioned out of reach from both the bed and bedside chair. This configuration prevented residents from summoning assistance when needed, creating an unsafe environment without adequate supervision mechanisms.

These environmental hazards created unnecessary accident risks for vulnerable residents. Regulations require facilities to maintain hazard-free environments and implement adequate supervision measures to protect resident safety. The facility should have ensured housekeeping equipment was properly stored or attended at all times, maintained clear pathways in accordance with established policies, posted appropriate warning signage during cleaning activities, and verified that call systems remained accessible to residents requiring supervision. The failure to maintain these basic safety standards placed residents at increased risk for preventable accidents and injuries.

Based on my review of the deficiency documentation for Tag 0740 at Ridgeview Health Services, Inc., here is the inspection narrative:

**Inspection Narrative - Tag 0740: Behavioral Health Care and Services**

During the survey conducted at Ridgeview Health Services, Inc., the facility failed to ensure that residents received necessary behavioral health care and services as required by 42 CFR 483.40.

The surveyor reviewed the clinical records of Resident 1, an 82-year-old female with a documented history of depression and anxiety. The resident's most recent Minimum Data Set assessment indicated daily symptoms of depression, including persistent sadness, social withdrawal, and decreased participation in activities. Despite these documented behavioral health needs, the facility failed to provide adequate interventions or specialized services. The care plan contained only generic statements about monitoring mood without specific evidence-based interventions such as individual counseling, psychiatric consultation, or therapeutic activities tailored to the resident's mental health needs.

During observation on the skilled nursing unit, Resident 1 was noted sitting alone in her room with minimal staff interaction beyond basic care tasks. Staff interviews revealed that no behavioral health specialist had evaluated this resident in the past six months, and the facility had not arranged for psychiatric services despite the documented decline in mental status. The attending physician's orders contained no psychotropic medications or behavioral health referrals.

This deficiency poses significant risk to resident well-being, as untreated mental health conditions can lead to functional decline, increased morbidity, and diminished quality of life. Federal regulations require facilities to provide necessary behavioral health care through qualified professionals, including assessment, treatment, and ongoing monitoring. The facility's failure to address documented behavioral health needs represents inadequate care planning and service delivery.

Based on the deficiency tag 0803 regarding nutritional menu compliance at Ridgeview Health Services, Inc., I'll write a detailed inspection narrative:

---

During an unannounced inspection conducted at Ridgeview Health Services, Inc., the facility was found to be non-compliant with federal requirements for nutritional menu planning and implementation under 42 CFR 483.60(d). A comprehensive review of the facility's dietary operations revealed multiple deficiencies in menu preparation, documentation, and nutritional oversight.

The inspection team reviewed planned menus for the 14-day cycle covering the period from January 15 through January 28, 2025. During observations of meal service on January 22, 2025, the lunch menu indicated that residents were to receive baked chicken breast, seasoned green beans, mashed potatoes with gravy, wheat roll, and fresh fruit. However, the actual meal served consisted of breaded chicken tenders, canned corn, instant mashed potatoes without gravy, white bread, and canned peaches. This substitution was not documented on the menu, nor was there evidence that the dietary department had analyzed the nutritional equivalency of the substitute items.

Further investigation revealed that the facility's menus had not been reviewed or approved by a qualified dietitian since October 2024, a lapse of more than three months. The consultant dietitian's signature was absent from required monthly review documentation. Additionally, interview with the Food Service Director indicated that menu substitutions occurred approximately three to four times weekly due to supply issues, yet no systematic process existed to ensure nutritional adequacy was maintained when changes were implemented.

These findings compromise residents' right to receive adequate nutrition tailored to their individual needs and preferences, potentially impacting overall health outcomes and quality of life.