Arc at Sangamon Valley: Hoyer Lift Fall Injures Resident - IL
The incident happened on October 4, 2025, between 7:00 and 7:30 in the evening. The CNA, identified in inspection records as V9, noticed the resident, identified as R2, slouching in her wheelchair and decided to put her to bed. V9 got R2 secured in the lift, walked out of the room to find a second staff member, didn't find one, and proceeded with the transfer alone. She told inspectors she had done transfers by herself several times.
V9 had R2 lifted and was maneuvering the wheelchair with one hand and the lift with the other when the device rolled over the floor mat. The lift caught on the mat and tipped completely. R2 hit her head, and it was busted open. R2 was sent to the hospital for evaluation.
The floor mat was there for a reason. R2 had it in place as a fall prevention measure. The LPN on duty, V7, told inspectors the mat should be moved during any transfer. V7 wasn't in the room when it happened. The aide came to tell her afterward.
The facility's own administrator, identified as V1, told inspectors that Hoyer lift transfers require two staff present and that a floor mat should be moved before any transfer begins.
V9 confirmed both things had failed. No second staff member was in the room. The mat was not moved.
The inspection, conducted October 16, 2025, cited the fall as causing actual harm.
R2 was sent to the hospital with a head wound from a device meant to keep her safe.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Arc At Sangamon Valley from 2025-10-16 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 5, 2026 · Our methodology
Arc at Sangamon Valley in SPRINGFIELD, IL was cited for violations during a health inspection on October 16, 2025.
The incident happened on October 4, 2025, between 7:00 and 7:30 in the evening.
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.