The Haven of Ridgeview: Bed Frame Injury Sends Resident to ER - IL
The resident, identified in inspection records only as R1, was being transferred from her wheelchair to her bed at The Haven of Ridgeview when the injury happened. Two certified nursing assistants were working the transfer together, one standing in front of the wheelchair and one behind. When the CNA at the rear moved to reposition R1 for the mechanical lift, R1's left leg swung into contact with the right side of the bed frame. The cap that should have covered the end of that frame was gone. What was left was bare metal with sharp edges.
R1 has lymphedema, a condition that causes chronic swelling in the limbs and makes the skin fragile and prone to tearing. Her leg split open.
She was sent to the local emergency room that same evening. The emergency physician's note documented her chief complaint in plain terms: her leg got caught in the bed at the facility and she suffered a significant skin tear laceration. To stop the bleeding, the wound was injected with lidocaine and epinephrine. One stitch was added where bleeding continued. Her pain score was a two out of ten.
The facility's own wound nurse documented the visit in a progress note the same night, describing the injury as a skin tear to the left lower leg related to R1's lymphedema.
The next morning, during a routine staff meeting, someone noted that the black cap had been missing from R1's bed frame. It was replaced.
The Director of Nursing told inspectors she learned about the emergency room visit by phone from a licensed practical nurse. The administrator said the same, that she had been notified by phone that R1 had been sent out because she had hit her leg on her bed frame. The replacement of the cap came up in the morning meeting the following day.
When inspectors arrived on September 25, 2025, they observed a dressing change on R1's left lower leg, performed by a registered nurse with assistance from a second nurse and a physical therapy assistant. The laceration was healing.
The facility's mechanical lift policy, last revised in November 2023, includes a step directing staff to prepare the environment before a transfer, including ensuring there is enough room to pivot. It does not appear that anyone, before the transfer began, identified the missing cap or the exposed metal edge that had been left on R1's bed.
Federal inspectors cited the facility under the accident hazards tag, finding that the environment had not been kept free of preventable hazards. The violation was cited at the minimal harm level.
That classification reflects where R1 ended up, not what the injury required. A trip to the emergency room. A local anesthetic injected into a wound. A stitch to close it. Inspectors were still watching nurses change her dressing two weeks later.
The cap was replaced the morning after she came back from the hospital.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Haven of Ridgeview from 2025-11-16 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
The Haven of Ridgeview in OBLONG, IL was cited for violations during a health inspection on November 16, 2025.
Two certified nursing assistants were working the transfer together, one standing in front of the wheelchair and one behind.
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.