Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to notify the physician prior to a residents discharge for 1 of 3
residents (R1) reviewed for discharge planning in a sample of 5.
Findings Include:
Review of R1's admission Record documented R1's initial admission date to the facility as 08/02/2024 . The
same document lists diagnoses for R1 as the following: other acute osteomyelitis, left foot and ankle,
essential hypertension, alcohol use, and patient's other noncompliance with medication regimen.
R1's Minimum Data Set (MDS) with an Assessment Reference Date of 08/09/2024 documented a Brief
Interview for Mental Status Score of 15, indicating R1 is cognitively intact.
A Progress Note dated 09/14/2024 with a time of 12:24 P.M. authored by V5 (Registered Nurse)
documented R1 left the facility at 12:20 P.M., belongings, meds and narcotics sent with R1. R1 was
educated on care of his wound and given his follow up appointment schedule, R1 voiced understanding. R1
left the facility via private car with friend.
A form tiled (name of company)-Discharge Plan and Instruction with a date of 09/12/2024 documented that
R1 had follow up appointments with the locations, date and times. The form goes on to document no home
health care services were set up, no medical equipment needed, and medications were discussed with R1.
R1's Order Summary Report with a Active Orders as of 09/14/2024 printed on 10/30/2024, documented an
order dated 08/02/2024, for PICC (Peripherally Inserted Central Catheter) to be used for antibiotic use. The
same document documented an order dated 08/02/2024, for Ertapenem 1 GM(Gram) intravenously every
24 hours for infection for 6 weeks. There were no orders documented on R1's Order Summary Report from
V7 regarding R1's discharge or follow up care for the management of the PICC line.
R1's Care Plan with and initiation date of 08/17/2024 has a Focus area of: Potential for infection related to
IV (intravenous) use of PICC Line. The same document listed Goal: Will have no signs and symptoms of IV
related complications. The same document goes on to list the interventions as administer medications as
ordered, change catheter site dressing as required, change IV tubing as ordered, change sterile cap as
ordered, labs as ordered, and monitor the site for redness, swelling, and or drainage. The same document
went on to list a Focus Area of: The resident wishes to return/be discharged to home. The Goal is listed as:
The resident will communicate an understanding of the discharge
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
146096
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146096
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/01/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Haven of Ridgeview
413 Ridge Lane
Oblong, IL 62449
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
plan and describe the desired outcome. The same document went on to list the interventions as: encourage
the resident to discuss feelings and concerns with discharge, evaluate the residents motivation to return to
the community, make arrangements with required community resources to support independence post
discharge, and prepare and give the resident contact numbers for all community referrals.
On 10/30/2024 at 9:40 A.M. V3 (Hospital Social Service Worker) stated that R1 presented to the
emergency room on [DATE] with the same PICC line in that was supposed to be taken out before he left the
facility. V3 stated that R1 was discharged from the hospital and admitted to the facility on [DATE] for IV
antibiotics. R1 was supposed to be discharged from the facility with the PICC line discontinued due to R1
having a history of being a known drug user and homeless. V3 stated that according to the discharge
instructions that the facility was given from the hospital when R1 was admitted to the facility, R1 was to
complete his antibiotics on 09/12/2024. V3 stated that R1 had an infection of his foot that required weeks of
IV (Intravenous) antibiotics. V3 stated that once R1 was discharged from the facility there was no one
caring for the PICC line and that R1 was living off of friends' couches. V3 stated that R1 told the emergency
room staff that he was tying a belt around the PICC line to keep it from hanging down. V3 stated that once
R1 was readmitted to the hospital on [DATE], they completed a culture of his foot where the wound was and
placed a new PICC line for further treatment with IV antibiotics. V3 stated that R1 was discharged to
another facility for further treatment.
Review of Progress Note from local hospital dated 10/21/2024 timed 10:08 P.M. authored by V4 (Hospital
Emergency Department Physician) documented Patient reportedly left the nursing home with PICC line,
possibly AMA case management consulted and will be investigating.
On 10/30/2024 at 1:53 P.M., an attempt was made to contact R1 at the number provided on R1's facility
admission Record and the number is not a working phone number.
On 10/30/2024 at 12:13 P.M. V1 (Administrator) stated that R1 was in the facility with a PICC line to receive
IV antibiotics related to an infection he had in his foot. V1 stated that R1 was reported to be homeless
before coming to the facility. V1 stated that the local hospital had called on 10/23/2024 to ask questions
about R1. V1 stated that she verified to the hospital that R1 had completed his antibiotic and she believed
that his PICC line was taken out before he was discharged . V1 then stated that she verified with V2
(Director of Nursing) if the PICC line was removed before discharge. V1 did state that the hospital asked
her if R1's discharge was planned and V1 stated that she explained the process to the case manager at the
hospital. V1 stated that she verified to the hospital that R1 had completed his antibiotic and she believed
that his PICC line was taken out before he was discharged .
On 10/30/2024 at 12:40 P.M. V2 (Director of Nursing) stated that R1 was at the facility for IV antibiotics
related to osteomyelitis of his foot. V2 stated that he was supposed to be discharged after his last dose of
antibiotics, but his ride couldn't come get him for a day or two. V2 stated that the plan was for R1 to return
to his girlfriend's house after antibiotics were completed. V2 stated that R1 was sent home with medications
and dressing supplies so he could do the dressings on his foot. R1 was also sent home with all of his
medical follow up appointments. V2 stated that she was pretty sure the PICC line was taken out on the day
the antibiotics were completed. V2 stated R1's last dose of antibiotics would have been 09/12/2024. V2
stated that it was her understanding that the PICC line was discontinued before R1 was discharged .
On 10/30/2024 at 1:30 P.M. V5 (Registered Nurse) stated she was R1's nurse the day of discharge. V5
stated that she went over in length the importance of following up with all of his medical
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146096
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146096
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/01/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Haven of Ridgeview
413 Ridge Lane
Oblong, IL 62449
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0580
Level of Harm - Minimal harm
or potential for actual harm
appointments when he is discharged . V5 stated that she is not sure if R1 still had his PICC line when he
was discharged . V5 stated she did not do a skin check like you would on admission. V5 stated that she
really did not know one way or another if R1 still had his PICC line and she can't really answer the question.
V5 stated that she did not call the physician for discharge orders because she just thought they were
already on the chart. V5 stated that she did not look to see if there were orders or not.
Residents Affected - Few
On 10/30/2024 at 2:11 P.M. V6 (Registered Nurse) stated that she gave R1 his last dose of IV antibiotic on
09/12/2024. V6 stated she did not pull the PICC line out at that time. V6 stated she was off the next two
days and did not take care of R1 anymore after 09/12/2024.
On 10/31/2024 at 9:20 A.M. V1 stated she cannot find documentation in the chart for R1 to be discharged
or for the PICC line to be removed. V1 stated that she is not sure why there is not an order in the electronic
medical record for R1 to be discharged . V1 stated that R1's discharge was planned. V1 stated that all staff
and V7 (Medical Doctor) was aware that R1 was going to leave as soon as his antibiotics were completed.
V1 stated that R1 was given (company name)- Discharge Plan and Instructions form as well as a current
medication list.
On 10/31/2024 at 10:22 A.M. V7 (Medical Director) stated that she saw R1 on 09/04/2024 at the facility. V7
stated that she was made aware on 09/04/2024 by R1 and the facility that R1 wanted to be discharged after
he completed his IV antibiotics. V7 stated there was no direct communication with the facility to her office
about R1 going home. V7 stated that she did not give orders to the facility for R1 to be discharged . V7
stated that she has an office nurse who is responsible for her facility patients and the nurse was not made
aware that the facility needed discharge orders. V7 stated that she would have expected the facility to
discontinue R1's PICC line prior to him being discharged . V7 stated that it is standard routine care to
discontinue a PICC line once the course of IV antibiotics were completed.
On 10/31/2024 at 10:37 A.M. V2 (Director of Nursing) stated that it is her expectation for the nursing staff
obtain discharge orders prior to discharge. V2 also stated that it is her expectation for PICC lines to be
discontinued before discharge. V2 stated that there should be orders for these in the electronic medical
record.
The facility policy titled Discharge / Transfer Policy with a revision date of 08/15/2022 documented under the
section titled purpose, 1. When the facility transfers or discharges resident under any circumstances,
appropriate documentation shall be made in the resident's clinical record. The attending physician shall give
orders for the transfer / discharge. 3. A written or telephone order is required from the attending physician
for the transfer or discharge of a resident except in emergency situations.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146096
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
FAQ · About this visit
Common questions about this visit
What happened during the November 1, 2024 survey of The Haven of Ridgeview?
This was a inspection survey of The Haven of Ridgeview on November 1, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at The Haven of Ridgeview on November 1, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) tha..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.