Arc at Sangamon Valley: Lift Fall Splits Resident's Head - IL
That is what happened at Arc at Sangamon Valley on the evening of October 4, 2025, according to a complaint inspection completed October 16.
The resident, identified in inspection records as R2, was care-planned to be moved with two staff members using a full mechanical lift. That wasn't a suggestion. It was the documented plan for every transfer. On this night, between 7:00 PM and 7:30 PM, CNA V9 found R2 slouching in her wheelchair and decided to put her to bed.
V9 told inspectors she got R2 hooked up in the lift, walked out to find another aide, and came back empty-handed. Then she did the transfer anyway. She said she had done them alone several times before.
She had R2 lifted in the air, was moving the wheelchair with one hand, and was steering the lift toward the bed with the other. There was a floor mat next to the bed, the kind placed on the ground to cushion a fall. It was still there. V9 told inspectors she knew she should have moved it. She tried to roll the lift over it instead.
The lift caught on the mat and tipped over completely. R2 hit her head. V9 described the wound to inspectors: it was busted open. R2 was sent to the hospital for evaluation.
The LPN on duty, V7, told inspectors she was not in the room when it happened. An aide came and found her and told her the lift had tilted over. When V7 entered the room, the floor mat had already been moved from where it had been. She said she wasn't sure whether it had been beside the bed at the moment of the fall, though V9 confirmed to inspectors that it had been, and that she had not moved it before attempting the transfer.
The facility's administrator, V1, told inspectors that two staff are required for Hoyer lift transfers and that she would expect a floor mat to be moved before any transfer began. She did not dispute what had happened.
The facility's own fall prevention policy, dated 2012, states that residents' environments will be kept clear of hazards and that transfer equipment will be used in accordance with each resident's plan of care. Its mechanical lift policy, also from 2012, states that lifting devices are required for any resident needing a two-person assist or who cannot be safely transferred by normal technique.
R2 met both criteria. None of that mattered on the night of October 4.
After the fall, the facility convened its interdisciplinary team, updated R2's care plan, notified her physician and power of attorney, had maintenance inspect the lift, and educated staff on mechanical lift procedures and room preparation. R2 was being monitored for pain at the time of the inspection.
The inspectors cited the facility for actual harm under F0689, the federal tag covering accident hazards and supervision. The level of harm was not listed as immediate jeopardy, but the finding was actual harm, not potential.
What the record shows is a resident who was care-planned for a two-person transfer, left hanging in a mechanical lift while one aide went looking for help, and then moved anyway when no help appeared. The aide who made that decision told inspectors she had done it the same way multiple times before. The lift tipped. The head wound required a hospital trip.
R2 was already in the lift, already in the air, when V9 decided to keep going alone.
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.
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 25, 2026 · Our methodology
Arc at Sangamon Valley in SPRINGFIELD, IL was cited for violations during a health inspection on October 16, 2025.
That is what happened at Arc at Sangamon Valley on the evening of October 4, 2025, according to a complaint inspection completed October 16.
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.