Ridgeview Health Services, Inc

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:

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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.

#151 had any intent to harm RI #152.

When asked how a reasonable person would feel to have pillow

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Ridgeview Health Services, Inc 907 11th Street, NE Jasper, AL 35504

a wound vac would be needed.

When asked what the advantages were of having a wound vac, the

conducted an interview with Central Supply Staff (CCS) and she said she called the company the

asked was there another company the facility could have secured a wound vac from, the CCS said this was the only company the facility used.

The CCS presented the surveyor with a Service Ticket, dated 11/10/2022, which revealed the wound vac was delivered to the facility on [DATE] at 9:40 AM, four days after RI #150 was admitted to the facility.

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Ridgeview Health Services, Inc 907 11th Street, NE Jasper, AL 35504

During the survey the following observations of RI #16 were made: On 08/05/2025 at 3:58 PM RI #16's bed was observed with a fall mat on the floor on the left side of RI #16's bed. RI #16's bed was not in a lowered position. On 08/06/2025 at 8:27 AM RI #16's bed was observed with a fall mat on the floor on the left side of RI #16's bed and RI #16's bed was again observed not to be in a lowered position. On 08/06/2025 at 3:22 PM RI #16 was observed to have a floor mat only on the floor on the left side of the bed and the bed was not in a lowered position. On 08/07/2025 at 7:52 AM the surveyor again observed a fall mat on the floor only on the left side of RI #16's bed and the bed was not in a lowered position. On 08/07/2025 at 11:43 AM a telephone interview was conducted with Registered Nurse (RN) #14, the nurse assigned to care for RI #16 on 12/07/2024, the evening RI #16 was observed on the floor.

When asked what type of fall interventions were put in place after RI #16 was observed on the floor, RN #14 said fall mats were to be on both sides of the bed, and the bed was to be lowered when RI #16 was in the bed. On 08/07/2025 at 2:55 PM a telephone interview was conducted with Certified Nursing Assistant (CNA) #14, the CNA assigned to care for RI #16 on the evening RI #16 was observed on the floor.

When asked what type of fall interventions were put in place after RI #16 was observed on the floor on 12/07/2025, CNA #14 said the bed was to be kept in the lowest position. On 08/08/2025 at 11:36 AM the surveyor conducted an interview with CNA #9, RI #16's assigned CNA for the morning of 08/08/2024.

The surveyor shared with CNA #9 that the surveyor had observed on 08/05/2025, 08/06/2025 and on 08/07/2025 that RI #16 only had a mat on the left side of the bed and RI #16's bed was not lowered to the floor. CNA #9 said it would be important to ensure a resident's fall interventions were being implemented so the resident would not fall and hurt themselves. On 08/08/2025 at 2:17 PM the surveyor conducted an interview with RN #10, one of the Unit Managers for the hall RI #16 resided on.

When asked how staff would know the type of fall interventions a resident had in place, RN #10 said it would be on the resident's profile. RN #10 said according to RI #16's plan of care, fall interventions were put in place after RI #16 had a fall on 12/07/2024. RN #10 said fall mats were to be at the bedside, and the bed was to be let down as far as it would go. RN #10 said the CNAs would be made aware of the fall interventions by looking at the resident's profile. RN #10 said whatever order was on RI #16's profile should have been in place on 08/05/2025, 08/06/2025 and on 08/07/2025.

When asked why it would be important to ensure a resident's fall interventions were being implemented, RN #10 said to avoid injury.

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Ridgeview Health Services, Inc 907 11th Street, NE Jasper, AL 35504

#151 from the room and notified the supervisor. CNA #12 said, it could have been prevented if

other beds, and would fight back when staff attempted to provide redirection. CNA #12 said RI #151

On 08/08/2025 at 2:41 PM an interview was conducted with the Director of Nursing (DON) regarding RI #151's behaviors as identified on RI #151's behavioral care plan. DON said that RI #151 had behaviors such as wandering constantly, refusing care, spitting out meds, wandering into other residents room and requiring staff redirection. DON said specific goals identified on RI #151's behavioral care plan were; behaviors will not pose a danger to self or others, will not interfere with Activity of Daily Living and will be easily redirected.

When asked why it was important to respond according to the care plan, DON said to help deescalate potential issues, and the care plan specifically targets interventions for that particular resident.

The DON said residents wandering into others room could potentially upset other residents and interfere with other residents privacy. On 08/07/2025 at 3:00 PM the Social Worker (SW) was asked about RI #151's behaviors, and she said, RI #151 exhibited wandering behaviors, spitting out meds, taking other items.

The SW said wandering was not uncommon for residents on the Dementia unit and staff would provide redirection.

When asked what interventions were used to prevent RI #151 from wandering into other residents rooms, she said walking with RI #151, sitting/ talking and reminiscing or providing activity.

When asked if these interventions were done the night of 03/31/2023 when RI #151 was wandering, she said she did not know.

When asked if RI #151 was exhibiting wandering behavior the evening of 03/31/2023, what should staff have done, the SW said, walk with RI #151 or provided redirection.

The SW said when staff became aware of the incident, they intervened, provided redirection, notified the supervisor and RI #151 was sent out to the behavioral unit.

When asked what could have been done to prevent RI #151 from wandering into RI #152's room, she said she did not see how it could have been prevented as RI #151 was very unpredictable.

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Ridgeview Health Services, Inc 907 11th Street, NE Jasper, AL 35504

During a kitchen observation on 08/06/2025 at 4:45 PM, the Dinner trayline included the following:Cheeseburger SoupCreamy Onion and Tomato Salad Pureed Cheeseburger Soup Pureed Carrots (substituted for the Creamy Onion and Tomato Salad) Fortified Mashed Potatoes (with butter and sour cream added to increase calories) At 5:30 PM on 08/06/2025, the use of blue-handled scoops for the Pureed Cheeseburger Soup, Pureed Carrots, and Fortified Mashed Potatoes was questioned.

The Nutrition Department Director checked the menu and the scoops being used.

The three blue-handled scoops being used were verified to be size #16 scoops.

The Nutrition Department Director instructed staff to get size #8 scoops and these were put in place for use.

Three of eleven Puree diets had been served, because the Nutrition Aide counted eight Pureed Diet menu slips remaining to be served. On 08/06/2025 at 6:26 PM, the Relief [NAME] In-Training was interviewed.

The Relief [NAME] In-Training said the scoops (blue-handled, #16 scoops) were already in the food pans on the trayline and he did not know who placed them there. On 08/06/2025 at 6:30 PM, the Nutrition Manager was interviewed.

The Nutrition Manager said she did not know who placed the blue-handled, #16 scoops in the food pans.

The Nutrition Manager further said the regular PM [NAME] had been helping the Relief [NAME] In-Training, but she had left before the trayline started. On 08/07/2025 at 11:45 AM, a follow-up interview was conducted with the Nutrition Manager.

The Nutrition Manager said the Wednesday Dinner menu for S/S (Spring/Summer) Week 2, Day 11 specified a number eight (#8) dip, which is also called a number 8 scoop, be used twice for each serving of Pureed Cheeseburger Soup.

The Nutrition Manager further said a number 8 dip (scoop) should have been used for the Pureed Carrots, which were substituted for the Pureed Creamy Tomato & Onion Salad.

The Nutrition Manager additionally said a number 8 dip (scoop) was to be used for the Fortified Mashed Potatoes.

The Nutrition Manager said there was a problem with using a #16 scoop (1/4 cup) instead of a #8 scoop (1/2 cup); as the nutrition value would be affected due to the residents not getting enough food.

The Nutrition Manager further said it could result in weight loss. On 08/07/2025 at 11:45 AM, immediately following the interview with the Nutrition Manager, the Nutrition Department Director was interviewed.

The Nutrition Department Director was asked the problem with using a size #16 scoop instead of a size #8 scoop to serve the Pureed Cheeseburger Soup (#8 scoop times two), the Pureed Carrots, and the Fortified Mashed Potatoes.

The Nutrition Department Director said it was not enough food, it was an inadequate serving, and if continued over time the residents could lose weight.