Arc At Sangamon Valley
Arc at Sangamon Valley in SPRINGFIELD, IL — inspection on October 16, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
lift was being used.
The resident was being cared for at time of injury and is care planned to be transferred with an assist of 2 utilizing a mechanical lift.
The IDT team reviewed the incident, and the care plan was reviewed and updated.
Resident is being monitored for pain.
Staff were educated on using the mechanical lifts as well as room preparation prior to using the lifts.
Maintenance inspected the machine to ensure good working order. MD and POA were notified of plan of care and agreeable. On 10/1625 at 12:40 PM, V7, LPN (Licensed Practical Nurse), stated she was working when R2 fell from the Hoyer lift, but she was not in the room when it happened. V7 stated the aide came to her and stated they were putting R2 to bed and the full mechanical lift tilted over. V7 stated there was a floor (fall) mat in place next to R2's bed but it had been moved when she entered the room, so she isn't sure if it was by the bed when R2 was being transferred. V7 stated R2 was sent to the hospital for evaluation. V7 stated if a resident has a floor mat in place, it should be moved during the transfer. On 10/16/25 at 12:48 PM, V9, CNA, stated on 10/4/25 between 7:00 PM and 7:30 PM, she noticed R2 was in her wheelchair slouching down, so she was going to put her in bed. V9 stated she got R2 hooked up in the full mechanical lift, walked out of the room to get another CNA, she didn't see one, so she did the transfer by herself and has done them by herself several times. V9 stated she had lifted R2 up in the lift, was moving the wheelchair while her other hand was on the full mechanical lift moving it towards the bed and over the floor mat. V9 stated she should've moved the mat but didn't, she tried moving the lift over the mat, the lift caught on the mat and tipped over completely. V9 stated R2 hit her head, and it was busted open. V9 verified there were no other staff in the room during the transfer, and she did not move the floor mat prior to the transfer. On 10/16/25 at 1:05 PM, V1, Administrator, stated when using the Hoyer lift, there should be 2 staff present and she would expect that if a floor mat was in place, it be moved prior to the transfer.
The Fall Prevention Program Policy, dated 11/2012, documents the following: The purpose of the policy is to assure the safety of all residents in the facility, when possible.
The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary.
The resident's environment will be kept clear of clutter which would affect ambulation and remove hazards.
Transfer conveyances shall be used to transfer residents in accordance with the plan of care.The Transfers - Manual Gait Belt and Mechanical Lifts Policy, dated 11/2012, documents the following: In order to protect the safety and well-being of the staff and residents, and to promote quality care, this facility will use mechanical lifting devices for the lifting and movement of residents.
Mechanical lifting devices shall be used for any resident needing a two person assist, or who cannot be transferred comfortably and/or safely by normal transfer technique.
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