F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure wheelchairs were clean for 1 of 5
residents (R2), reviewed for safe/clean/comfortable/homelike environment in the sample of 5.Findings
include:On 7/1/25 at 9:00 AM, R2 was observed in her wheelchair, in the dining room. The wheelchair had
dried debris on the edges of the seat, wheels, and frame.On 7/1/25 at 12:45 PM, R2 stated the facility staff
is to clean her wheelchair once a month, but she isn't sure if they do it.R2's Minimum Data Set, dated
[DATE], documents R2 has a BIMS (Brief Interview of Mental Status) score of 14, indicating R2 is
cognitively intact.On 7/1/25 at 4:00 PM, V1, Administrator, stated he will make sure R2's wheelchair is
cleaned. The Cleaning & Sanitizing - Wheelchairs and Other Medical Equipment, dated 11/20/12,
documents the following: Medical equipment/devices will be cleaned and sanitized weekly or more often if
needed, when used by the same resident.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
146026
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146026
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/01/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arc at Sangamon Valley
3400 West Washington
Springfield, IL 62711
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure fall interventions were in place in 1 of
4 residents (R3), reviewed for falls in the sample of 5.Findings Include: R3's Face Sheet, undated,
documents R3 has the following diagnoses: Dementia, History of Falling, and Chronic Kidney Disease.R3's
Minimum Data Set, dated [DATE], documents R3 has moderate cognitive impairment, utilizes a wheelchair
for mobility, and is dependent upon staff for chair/bed transfers. R3's Care Plan, dated 10/5/23, documents
R3 is at risk for falls with the following interventions: Tilt Broda (reclining wheelchair) back in a reclining
position when she is up and is not eating, keep furniture in locked position, and placement of a reminder
sign to lock the Broda chair brakes when resident is sitting at the table due to resident pushing herself away
from the table and is unbalanced and will lean forward causing unbalanced trunk movements.On 7/1/25 at
1:10 PM, R3's reclining wheelchair was observed with brakes to all four wheels and a sign on it
documenting to make sure the brakes were locked and the chair was tilted backwards when R3 was in it.
On 7/1/25 at 1:00 PM, V12, R3's family, stated the problems in the facility are ongoing. V12 stated R3 had a
fall recently and had to go the ER/emergency room, she didn't have to get any stitches or have any bleeds.
V12 stated when R3 is up in her chair, she is to have her wheelchair locked and she is to be leaned back.
V12 stated R3 fell in the dining area, and she feels that staff didn't have her wheelchair locked or leaned
back. V12 stated R3 used the table pushing herself backwards and fell out of her chair and smacked her
head. V12 stated this was never confirmed or denied by the facility but she has requested the nurses
report. V12 stated she doesn't believe there is enough oversight in the dining room, it is just dining staff and
not enough CNAs (Certified Nursing Assistants) or nurses supervising. V12 stated R3 has fallen a few
times, that is why she has signs all over her room reminding them to lock her wheelchair and tilt it
backwards. R3's Progress Note, dated 6/24/25 at 10:23 AM, documents the nurse was called to the dining
room by the activity aide. Resident was observed lying on the floor on her right side. Head laceration to the
forehead. Complaints of pain to the head and right hip. Full mechanical lift sling lying on the floor with her.
One wheel locked on the wheelchair. Resident transferred to local emergency room for further
evaluation.R3's Progress Note, dated 6/23/25 at 10:53 AM, documents the interdisciplinary team met
regarding recent fall. Resident was in the dining room when she pushed herself away from the table and
fell. Resident unable to state what happened. Root cause: pushed self away from the table. Intervention:
send to emergency room for evaluation and treatment. R3's Progress Note, dated 6/24/25 at 10:18 AM,
documents the interdisciplinary team met regarding recent fall. Resident returned from the hospital with no
major injury. Hematoma to the right forehead. Intervention: monitor bruising to forehead, add non-skid
material to wheelchair and schedule acetaminophen for pain control. On 7/1/25 at 4:00 PM, V1,
Administrator, stated he is aware of V12's concerns with R3's fall and has spoken with her about this. The
Fall Prevention Program policy, dated 11/20/12, documents 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.
Event ID:
Facility ID:
146026
If continuation sheet
Page 2 of 2
