Arc At Sangamon Valley
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
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 Resident 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 Resident R2 to bed and the full mechanical lift tilted over. V7 stated there was a floor (fall) mat in place next to Resident 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 Resident R2 was being transferred. V7 stated Resident 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 Resident R2 was in her wheelchair slouching down, so she was going to put her in bed. V9 stated she got Resident 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 Resident 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 Resident 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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Arc at Sangamon Valley in SPRINGFIELD, IL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SPRINGFIELD, IL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Arc at Sangamon Valley or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.