Arc At Hickory Point
Inspection Findings
F-Tag F0921
F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
Based on observation and interview, the facility failed to maintain a resident bathroom/shower in clean condition for two residents (Resident R1,Resident R2) of four residents reviewed for environment in a sample list of seven residents. Findings Include:On 9/18/25 at 9:00AM in Resident R1's and Resident R2's room private bath with shower, there was an area above the shower head on the grout line approximately 5 inches by a half inch and an area above the shower where the ceiling meets the drywall approximately 12 inches by 6 inches that were covered by a slimy, fuzzy, black material with the appearance of black mold. On 9/18/25 at 9:05AM, V5, Housekeeper, stated, That black stuff has been in the shower for quite a while. I have turned in a work order and maintenance knows about it. On 9/18/25 at 9:15AM, V1, Administrator, and V7, Corporate Administrator, verified a slimy, fuzzy, black material was present above the shower in Resident R1's and Resident R2's room.
V7 stated, This will be taken care of immediately. We will close off the bathroom until it can be fixed. On 9/18/25 at 11:00AM, V1, Administrator, stated, I have looked back for three months and I can't see where there has been a work order for this.
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
Event ID:
ARC AT HICKORY POINT in FORSYTH, 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 FORSYTH, 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 HICKORY POINT or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.