8 Reports
Inspection Report — Oct 28, 2025
Complaint Investigation State
Date: Oct 28, 2025
Visit Reason
Investigation of Complaints #130020-C and #130387-C at Ridgeview Assisted Living - Marion.
Complaint Details
Investigation of Complaints #130020-C and #130387-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaints.
Inspection Report — Aug 21, 2025
CMS
Date: Aug 21, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with Medicare/Medicaid requirements regarding providing residents with current Advanced Beneficiary Notice (ABN) and Notice of Medicare Non-Coverage (NOMNC) documents at the end of skilled care.
Findings
The facility failed to provide current ABN and NOMNC forms for 3 of 3 residents reviewed, despite using outdated versions of these forms. Interviews with the Director of Nursing and Administrator confirmed lack of awareness about updated forms and the process to obtain them.
Violations (1)
F 0582: The facility failed to provide residents ending skilled care with current Advanced Beneficiary Notice (ABN) and Notice of Medicare Non-Coverage (NOMNC) documents for 3 of 3 residents reviewed.
Report Facts
Residents reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Responsible for completing ABN's and NOMNC's; interviewed regarding form usage and process | |
| Administrator | Interviewed regarding awareness of updated forms and process to obtain them |
Inspection Report — Mar 26, 2025
Complaint Investigation CMS
Date: Mar 26, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident wandering into another resident's room and inappropriate physical contact.
Complaint Details
The complaint investigation substantiated that Resident #1 wandered into Resident #3's room multiple times, touched her belongings and person, and was resistive to staff redirection. Staff acknowledged insufficient supervision and failure to keep Resident #1 safe and separated from other residents.
Findings
The facility failed to prevent Resident #1 from wandering into Resident #3's room multiple times and touching her belongings and person. Staff interviews and resident reports confirmed inadequate supervision and failure to keep Resident #1 from entering other residents' rooms.
Violations (1)
F 0689: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. The facility failed to prevent Resident #1 from wandering into another resident's room and making physical contact.
Report Facts
Residents present: 29
Behavior days: 7
Wandering days: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aid (CNA) | Reported Resident #1 wandering incidents and physical aggression |
| Staff B | Certified Nurse Aid (CNA) | Reported Resident #1 wandering and need for supervision |
| Staff D | Licensed Practical Nurse (LPN) | Reported Resident #1 wandering and resistive behavior |
| Director of Nursing | Director of Nursing (DON) | Reported on Resident #1's wandering and communication with Administrator |
| Administrator | Administrator | Reported facility policy coverage for resident incidents |
Inspection Report — Feb 11, 2025
Complaint Investigation State
Date: Feb 11, 2025
Visit Reason
The inspection was conducted related to the investigation of Complaint #121429-C and the recertification visit to determine compliance with certification for an Assisted Living Program.
Complaint Details
The visit was triggered by Complaint #121429-C. The complaint was investigated as part of the inspection.
Findings
The program failed to document nurse's notes by exception for current and discharged tenants and failed to update service plans to reflect tenants' current service needs, including medication administration and treatment management.
Violations (2)
Failure to document nurse's notes by exception for 1 of 4 current tenants and 2 of 2 discharged tenants.
Failure to update service plans as needed to reflect the service needs of tenants, including medication self-administration and treatment management.
Report Facts
Number of tenants without cognitive impairment: 23
Number of tenants with cognitive impairment: 0
Number of current tenants reviewed: 4
Number of discharged tenants reviewed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assisted Living Director of Nursing | Interviewed and confirmed nurse's notes and service plans were provided for tenants reviewed |
Inspection Report — Aug 15, 2024
Routine CMS
Date: Aug 15, 2024
Visit Reason
Routine inspection conducted to assess compliance with regulatory requirements including resident dignity, abuse prevention, food safety, sanitation, and quality assurance.
Findings
The facility was found deficient in maintaining resident dignity related to catheter care, preventing physical abuse, holding hot foods at safe temperatures, maintaining sanitary kitchen conditions, and conducting effective Quality Assurance and Performance Improvement activities.
Violations (5)
F 0550: The facility failed to ensure dignity for residents with catheters by not placing catheter bags in dignity bags for 2 of 4 residents reviewed, making catheter bags visible to staff, residents, and visitors.
F 0600: The facility failed to prevent physical abuse when a staff member hit a resident on the shoulder after an altercation, affecting 1 of 1 residents reviewed for abuse.
F 0804: The facility failed to hold hot foods at the required minimum temperature of 135°F during 1 meal service observed, with multiple food items below this temperature.
F 0812: The facility failed to store and prepare food under sanitary conditions in 3 kitchen areas, including dirty dishwashers, dust, food debris, and inadequate dishwasher temperatures below the required 160°F.
F 0865: The facility failed to carry out Quality Assurance activities effectively to investigate and address problems affecting quality of care, quality of life, and resident safety.
Report Facts
Dishwasher temperatures below required minimum: 14
Hot food temperatures: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Named in physical abuse incident involving Resident #23 |
| Staff B | Certified Nursing Assistant (CNA) | Witnessed transfer and incident involving Resident #23 |
| Staff C | Certified Nursing Assistant (CNA) | Witnessed and reported physical abuse incident involving Resident #23 |
| Staff D | Dietary Aide | Measured food temperatures and dishwasher temperatures |
| Staff E | Dietary staff involved in dishwasher temperature monitoring | |
| Director of Nursing | Director of Nursing | Provided interview regarding catheter dignity bag use |
| Administrator | Administrator | Provided interview regarding staff expectations and QA activities |
Inspection Report — Feb 15, 2024
Routine CMS
Date: Feb 15, 2024
Visit Reason
Routine inspection to assess compliance with regulatory standards including resident dignity, medication care planning, call light response times, food service sanitation, and infection control.
Findings
The facility was found deficient in serving meals in a dignified manner for some residents, incomplete medication care plans, delayed call light responses, unsanitary food service conditions, failure to cover food and drinks during transport, and inadequate infection control practices related to clean linen transport.
Violations (5)
F 0550: The facility failed to serve 2 of 16 residents in the dining room in a dignified manner when meals were served on trays instead of plates.
F 0657: The facility failed to include anti-depressant and diuretic medications in the care plan for one resident reviewed for unnecessary medications.
F 0725: The facility failed to answer resident call lights in a timely manner, resulting in long wait times for 2 of 39 residents reviewed.
F 0812: The facility failed to ensure sanitary conditions in a food service area, monitor refrigerator temperatures, require hair coverings for all staff entering kitchenettes, cover food and drinks during transport, and serve all menu items to a resident on a pureed diet.
F 0880: The facility failed to cover clean linen carts during transport through hallways, violating infection control protocols.
Report Facts
Residents affected: 2
Call light response times: 24
Medication orders: 2
Cleaning schedule missing days: 4
Call light response times: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Reported expectations for meal service and call light response times |
| Dietary Manager | Dietary Manager | Reported expectations for food service hygiene and covering food during transport |
| Laundry Supervisor | Laundry Supervisor | Reported expectation that clean linen carts be covered during transport |
Inspection Report — Apr 25, 2022
Renewal State
Date: Apr 25, 2022
Visit Reason
The inspection was a recertification visit conducted to determine compliance with certification for an Assisted Living Program.
Findings
The program failed to follow its medication administration policy for 2 of 4 tenants reviewed, including incomplete medication reminders and documentation. Additionally, the program failed to update service plans as needed for 1 of 3 tenants reviewed, with outdated information regarding outside providers and therapies.
Violations (2)
Failed to follow policy and procedure related to Medication Administration for 2 of 4 tenants reviewed (Tenant #2, Tenant #3).
Failed to update service plans as needed for 1 of 3 tenants reviewed (Tenant #3).
Report Facts
Number of tenants without cognitive disorder: 30
Number of tenants with cognitive disorder: 4
Medication doses not documented as administered: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Brunscheen | Executive Director | Signed the Plan of Correction letter dated 5/20/22. |
| Director of Nursing | Interviewed regarding medication reminders and service plan updates; no full name provided. |
Inspection Report — Dec 11, 2019
Original Licensing State
Date: Dec 11, 2019
Visit Reason
The inspection was an initial certification visit to determine compliance with certification for an Assisted Living Program for People with Dementia.
Findings
The program failed to develop individualized service plans reflecting identified needs for 2 of 4 tenants reviewed, including failure to update service plans to reflect changes in physical therapy services and diagnosis of epilepsy.
Violations (1)
Program failed to develop service plans that reflected the identified needs for 2 of 4 tenants reviewed, including failure to update service plans for physical therapy and epilepsy diagnosis.
Report Facts
Number of tenants without cognitive disorder: 31
Number of tenants with cognitive disorder: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Brunscheen | Executive Director | Signed the plan of correction letter dated January 16, 2020 |
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