ARC at Hickory Point: Fall Injury With No Interventions - IL
The only protection anyone could point to was whether she was wearing the right shoes.
The resident, identified in inspection records only as R1, had been admitted to ARC at Hickory Point in Forsyth, Illinois. Her care plan, completed at admission by the facility's MDS and Care Plan Coordinator, listed falls as a problem. The single intervention documented: ensure R1 wore appropriate footwear. The coordinator told inspectors on September 3 that other fall interventions should have been included. She acknowledged they were not.
Three certified nursing assistants were interviewed separately. None of them described a meaningful fall prevention plan. One said the only thing she knew of was keeping the bed in the low position. Another said the same. A third said she didn't even know R1 was a fall risk, though she had seen colleagues lower the bed. None of them mentioned anything else, because there was nothing else.
The licensed practical nurse who was caring for R1 at the time of the fall told inspectors that R1 was a known fall risk and that no fall interventions were in place.
The Assistant Director of Nursing confirmed the fall risk assessment score and explained what that score was supposed to trigger: the development of appropriate interventions matched to the resident's specific risk level. She did not dispute that those interventions were missing.
The Regional Nurse Consultant offered an explanation. There was an IT issue with the care plan system, she said. Fall interventions should have been in place.
An IT problem. For a woman scored at high fall risk on her first full day in the building.
The Director of Nursing described R1 as pleasantly confused and easily redirected. She confirmed R1 was a fall risk. Then she said something that inspectors recorded without elaboration: having fall interventions in place could have changed R1's outcome.
The facility's former Medical Director, identified in the report as the physician, said the same thing in slightly different words. If proper fall protocols and precautions had been in place, it might have changed what happened to her.
What happened to her was documented in two imaging studies from July 10. The CT scan of her chest found multiple left-sided rib fractures, a hemothorax — blood pooling in the chest cavity — and a collapsed lung. The follow-up X-ray taken the same day showed the lung collapse had grown to moderate size, and the bleeding and bruising had increased. Her ribs, according to inspection records, showed visible and palpable deformity. Someone examining her chest could feel that something was wrong.
Federal inspectors cited the violation under F0689, which addresses the obligation to protect residents from accidents. The finding was tagged at the level of actual harm.
The inspection was a complaint investigation, conducted September 3, 2025, roughly two months after R1's fall and the imaging that followed. By the time inspectors arrived, the staff had already told their stories, the records had already been reviewed, and the answers were already consistent: she was high-risk, the plan was almost empty, and nobody had put anything meaningful between her and the floor.
The Director of Nursing knew it. The physician knew it. The care plan coordinator knew it. The nursing assistants who cared for her every day knew it, or in one case, didn't know her risk status at all.
What R1's outcome actually was, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Arc At Hickory Point from 2025-09-03 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: July 1, 2026 · Our methodology
ARC AT HICKORY POINT in FORSYTH, IL was cited for violations during a health inspection on September 3, 2025.
The only protection anyone could point to was whether she was wearing the right shoes.
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.