Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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 prevent injury for 1 of 3 (R3) residents
investigated for accidents in a sample of 3. R3's Undated Face sheet documents initial admission date
11/27/2023 diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant
side, iron deficiency anemia unspecified, unspecified osteoarthritis, unspecified site and unspecified
hearing loss, unspecified ear.R3's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for
Mental Status (BIMS) score of 15 out of 15.R3's MDS dated [DATE] documents resident needs
substantial/maximal assistance with sit to lying, lying to sitting onside of bed, assistance to sit to stand,
chair/bed to chair transfer and toilet transfer.R3's Care Plan addresses Resident is at a (moderate risk) for
abuse/neglect as noted from Abuse screening r/t (related to) depression symptoms and right sided
hemiparesis. Goal: Resident will be free for abuse/neglect through next review. Interventions: Resident has
right-sided hemiparesis, extra caution when transferring/adjusting resident.R3's Care plan addresses The
Resident needs assistance with ADL's (Activities of Daily Living). Goal: [NAME] will receive assistance as
needed to safely perform ADLs through review date. Interventions: Toileting: Assist of 1 with gait belt.
Transfers: Stand Pivot Assist x 2 with gait belt- SPT (stand pivot transfer) only.R3's Progress note dated
7/26/2925 at 2:00 PM documents During routine shower, Aide noted a bruise to residents right posterior
hand below her thumb. Bruise noted to be deep purple in color. When asked how it happened, resident
stated the CNA (certified nursing assistant) was kind of rough and impatient with her. Bruise was reported
to on call nurse along with residents' statement about the situation. After beginning the investigation and
getting statements from all staff members and resident, the aide assigned to her was suspended pending
further investigation. All parties were made aware of all.R3's Progress note dated 7/26/2025 at 10:17 AM
documents IDT (interdisciplinary teams) met to discuss fall from today. Resident was lowered to floor with
staff assist while ambulating in room. Root cause- Weakness Intervention- Refer to therapy services r/t
transfers.On 7/29/2025 at 10:49 AM R3 observed sitting in wheelchair, reading her book. R3 states V6,
Certified Nursing Assistant, (CNA) tried to get her up for breakfast a couple days ago. R3 states her right
side is paralyzed, but she R3 still does have some feeling. R3 states (V6) was forceful and pulled her right
side. R3 states (V6) then grabbed her bad right hand and put her fingernail into her right hand. R3 states
her right hand has a bruise under her thumb and a fingernail mark. R3 showed this writer her right hand,
has a quarter size dark purple bruise along with a small fingertip size scab above it. R3 states her right
hand is still sore. R3 states (V6) did not use the gait belt. R3 states most of the agency CNA's don't listen to
her, but the staff CNA's know her very well and take good care of her. R3 states staff mostly help when she
(R3) goes to restroom and will use a gait belt with 1 staff to assist. R3 states she (R3) has been here a long
time and most staff know her needs well. R3 states she (R3) can make her needs well known.On 7/29/2025
at 10:58 AM, V3, CNA,
(continued on next page)
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 4
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
08/01/2025
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
states (R3) need one assist and gait belt for assistance.On 7/29/2025 at 11:00 AM V4, Licensed Practical
Nurse, (LPN) states she was here the day (R3) got her injury to right hand. V4 states during medication
pass, (R3) was about to get a shower and told her she didn't feel comfortable with the (V6) giving her a
shower. (R3) requested V7, Restorative Aide, to give her a shower, as (R3) feels more comfortable with her.
V4 states (R3) is very particular with staff that she wants to give her care and who she trusts. V4 states she
looked at (R3's) right hand and saw very little bruising at that time.On 7/29/2025 at 11:18 AM V5, Police
Officer, states staff V8, Nurse Manager/Wound Nurse at Arc at Sangamon Valley contacted police
department regarding (R3). V8 states (R3) told him (V6) went to get her (R3) up. V8 states (R3) told (V6)
she is paralyzed on her right side, and (V6) did not listen. V8 states (R3) stated her right foot slipped into
the chair and hit her right hand. V8 states (V6) admitted she was in a hurry, and couldn't find the gait belt,
so she used the back of (R3's) bra strap to lift her and lost balance and slipped. V8 stated (R3) told her it
was okay to use the back of her bra strap. V8 states (R3) did not want to press charges and did not want to
get (V6) in trouble. On 7/29/2025 at 11:48 AM V6, Certified Nursing Assistant, (CNA) states on 7/26/2025 at
7:43 AM, (R3) was still asleep, so she gave her five more minutes. V6 states at 8:09 AM she got (R3) up for
breakfast, but (R3) wanted to do her exercises, although she knew (R3) needed to get up now and her son
was coming today. V6 states she could not find (R3's) gait belt, so she used (R3's) bra strap to grab and lift
her up. V6 states (R3) told her she could use her bra strap. V6 states when she lifted (R3) up, then back
down, she hit her right arm and tensed up. V6 states she then saw (R3's) gait belt in another chair under
clothes. V6 states she was later told that (R3) requested V7 to give (R3) a shower. V6 states she
approached (R3) and asked why she requested (V7) to assist with a shower, (R3) told her that she felt she
didn't like her and felt more stable and comfortable with (V7). (R3) told her, We don't have a connection. V6
states she apologized to (R3).On 7/29/2025 at 1:00 PM V2, Director of Nursing, (DON) states a bra strap is
not acceptable to use if gait belt is not available. She states there are no alternatives to a gait belt.On
7/30/2025 at 10:52, V10, Director of Therapy states (R3) needs one assist with gait belt with transfers.R'3
written statement on 7/28/2025 by V7, Restorative Aide documents Nurse asked me to give a resident a
shower. Went to go get resident. While in the shower room I assisted the resident. Where I discovered a
bruise on rt hand thumb area. I asked what happened. She stated V6 did it. She (R3) would not state
anything else.R3's Preliminary 24-hour Abuse Investigation Report documents On 7/26/2025 at
approximately 2pm administrator was informed of a bruise on residents right hand. Resident stated it
happened during care with a CNA (certified nursing assistant) Investigation was initiated immediately. The
staff member indicated by the resident was immediately suspended pending investigation.Facility's
Transfers- Manual Gait Belt and Mechanical Lifts Policy last revised 08/2023 documents Purpose: 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. The transferring needs of
residents will be assessed on an ongoing basis and designated into one of the following categories: 0 =
Independent 1 = 1 person transfer (25% or less assistance from the caregiver) with gait belt 2 = 2 person
transfer with gait [NAME] (ONLY when use of mechanical lift is not possible) 6. Resident transferring and
lifting needs shall be documented in care plans and reviewed via care plan time frame and as needed.
Assessment of the resident's transferring needs shall include a. Mobility status b. Weight bearing ability c.
Cognitive status 8. Failure to comply with lifting guidelines may result in disciplinary action as deemed
appropriate. 9. Use of gait belt for all physical assist transfers is mandatory.
Event ID:
Facility ID:
146026
If continuation sheet
Page 2 of 4
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
08/01/2025
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 0697
Provide safe, appropriate pain management for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, observation, and record review the facility failed to provide pain medications to a newly admitted
resident for 1 of 3 (R2) residents investigated for medications in the sample of 20. R2's EMR (Electronic
Medical Record) undated documents that the resident was admitted to the facility on [DATE].R2's EMR
dated 4/18/25 documents a diagnosis of aftercare following joint replacement surgery and presence of right
artificial hip joint.R2's Care Plan dated 5/18/25 documents The resident is at risk for pain r/t (related to)
Osteoarthritis and RTHA (Reverse Total Hip Arthroplasty).R2's Physician Order dated 4/18/25 documents
Hydrocodone-Acetaminophen Oral Tablet 7.5-325 MG (Hydrocodone-Acetaminophen); Give 1 tablet by
mouth every 6 hours as needed for Pain.R2's Physician Order dated 4/18/25 documents tramadol HCl Oral
Tablet 50 MG (Tramadol HCl); Give 1 tablet by mouth every 6 hours as needed for pain.R2's MAR
(Medication Administration Record) dated April 2025 does not document that R2 received
Hydrocodone-Acetaminophen 7.5/325 mg, or Tramadol 50 mg on the evening of 4/18/25.R2's Controlled
Substance Proof of Use sheet dated 4/18/25 documents that R2 did not receive a Hydrocodone/APAP
tablet 7.5/325 mg until 4/19/25 at 11:40 am.R2's Controlled Substance Proof of Use sheet dated 4/18/25
documents that R2 did not receive a Tramadol 50 mg until 4/19/25 at 11:40 AM.On 7/30/25 at 9:03 AM,
V17, LPN (Licensed Practical Nurse) stated that she is pretty sure that R2's medication did not get here
until late. She stated that the pharmacy runs late and that only certain people have access to the
(Medication Distribution Machine).On 7/30/25 at 9:54 AM, R2 stated that he did not get his medication until
Saturday morning (4/19/25). He stated that his pain medication was not available Friday (4/18/25) evening,
and he was in a lot of pain. He stated that he did not sleep well because of the pain.On 7/30/25 at 10:30
AM, V2, DON (Director of Nursing) stated that she would expect a newly admitted resident to get their
medication on time. She stated that staff can pull medication from the (Medication Distribution
Machine).Facility's Pain Management Program dated 4/2025 documents To establish a program which can
effectively manage pain in order to remove adverse physiologic and physiological effects of unrelieved pain
and to develop an optimal pain management plan to enhance healing and promote physiological and
psychological wellness.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146026
If continuation sheet
Page 3 of 4
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
08/01/2025
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to provide medication on admission on 1 of 3 (R2) residents
investigated for quality of care in a sample of 20.R2's EMR (Electronic Medical Record) undated documents
that the resident was admitted to the facility on [DATE].R2's EMR dated 4/18/25 documents a diagnosis of
aftercare following joint replacement surgery and presence of right artificial hip joint.R2's EMR dated
4/18/25 documents a diagnoses of unspecified asthma and chronic obstructive pulmonary disease with
acute exacerbation (COPD).R2's Care Plan dated 5/18/25 documents The resident is at risk for pain r/t
Osteoarthritis and RTHAR2's Care Plan dated 5/18/25 documents The resident has altered respiratory
status/difficulty breathing r/t COPD.R2's Physician Order dated 4/18/25 documents
Hydrocodone-Acetaminophen Oral Tablet 7.5-325 MG (Hydrocodone-Acetaminophen); Give 1 tablet by
mouth every 6 hours as needed for Pain.R2's Physician Order dated 4/18/25 documents Apixaban Oral
Tablet 5 MG (Apixaban); Give 1 tablet by mouth every morning and at bedtime for anticoagulation.R2's
Physician Order dated 4/18/25 documents Doxycycline Hyclate Oral Tablet 20 MG (Doxycycline Hyclate);
Give 1 tablet by mouth two times a day for infection.R2's Physician Order dated 4/18/25 documents
tramadol HCl Oral Tablet 50 MG (Tramadol HCl); Give 1 tablet by mouth every 6 hours as needed for
pain.R2's MAR (Medication Administration Record) dated April 2025 does not document that R2 received
Apixaban 5mg, Doxycycline 20 mg, Hydrocodone-Acetaminophen 7.5/325 mg, or Tramadol 50 mg on the
evening of 4/18/25.On 7/30/25 at 9:03 AM, V17, LPN (Licensed Practical Nurse) stated that she is pretty
sure that R2's medication did not get here until late. She stated that the pharmacy runs late and that only
certain people have access to the (Medication Distribution Machine).On 7/30/25 at 9:54 AM, R2 stated that
he did not get his medication until Saturday morning (4/19/25). He stated that his pain medication was not
available Friday (4/18/25) evening, and he was in a lot of pain. He stated that he did not sleep well because
of the pain.On 7/30/25 at 10:30 AM, V2, DON (Director of Nursing) stated that she would expect a newly
admitted resident to get their medication on time. She stated that staff can pull medication from the
(Medication Distribution Machine).Facility's Medication Administration Policy dated 1/2015 documents
Medications must be administered in accordance with a physician's order, e.g., the right resident, right
medication, right dosage, right route, and right time.
Event ID:
Facility ID:
146026
If continuation sheet
Page 4 of 4
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
FAQ · About this visit
Common questions about this visit
What happened during the August 1, 2025 survey of Arc at Sangamon Valley?
This was a inspection survey of Arc at Sangamon Valley on August 1, 2025. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Arc at Sangamon Valley on August 1, 2025?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.