ARC at Hickory Point: Fall Neglect Causes Rib Fractures - IL
That was it.
The licensed practical nurse caring for the resident at the time of the fall told inspectors on September 3 that the resident had no fall interventions in place. Three nursing aides said the same thing. One said she didn't even know the resident was a fall risk. Another said the only thing some staff did was put the bed in the low position, an informal habit, not a documented protocol.
The MDS and Care Plan Coordinator confirmed she had completed a baseline care plan on admission that identified falls as a problem. She told inspectors that other interventions should have been included. They weren't.
When inspectors reached the Regional Nurse Consultant, the explanation was brief: there was an IT issue with the care plans. Fall interventions, she acknowledged, should have been in place.
The Director of Nursing described the resident as pleasantly confused and easily redirected. She also told inspectors that having fall interventions in place could have changed the resident's outcome.
The facility's former Medical Director agreed. Proper fall protocols and precautions, he said, might have changed what happened to her.
The fall risk assessment flagging this resident as high risk had been completed more than two months before she fell, on June 29, 2025. The score was documented. The risk was known. The x-ray taken after her fall showed the fractures, the bruising, the bleeding that had worsened.
The care plan still said: appropriate footwear.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
ARC AT HICKORY POINT in FORSYTH, IL was cited for neglect violations during a health inspection on September 3, 2025.
Three nursing aides said the same thing.
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.