Arc At Hickory Point

F 0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review the facility failed to identify and report an alteration in skin integrity to prevent a pressure ulcer for one (Resident R1) of four residents reviewed for quality of care. This failure resulted in Resident R1 developing a Stage 2 pressure ulcer to the middle of Resident R1's tailbone.Findings include:The facility's Skin Condition Assessment & Monitoring - Pressure and Non-Pressure Policy, dated 04/2025, documents that

the purpose of the policy is to establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure injuries, and other non-pressure skin conditions, and ensuring interventions are implemented.Resident R1's Care Plan, initiated on 05/22/2019, documents that Resident R1 is at risk for developing pressure ulcers and other impairments to skin integrity related to decreased mobility, pain, and weakness. This Care Plan includes an intervention dated 05/23/2019 for monitoring, reminding, and assisting to turn/reposition Resident R1 at least every two hours, more often as needed or requested, and to notify Resident R1's nurse immediately of any new areas of skin breakdown noted during bathing or daily care.Resident R1's CNA (Certified Nurse Assistant) Skin Attention Form (completed by CNA during resident bath) from 09/01/2025 through 10/01/2025 does not document any skin issues.Resident R1's Comprehensive Incident Fall assessment dated [DATE REDACTED] documents a skin tear on Resident R1's tailbone measuring 4.2 centimeters (cm) by 3.1 cm.Resident R1's Hospice Plan of Care Update Report dated 10/04/2025 documents that Resident R1 had a pressure ulcer/pressure injury to the tailbone area.On 10/09/2025 at 9:52 AM, V14, Assistant Director of Nursing (ADON), stated

she was not aware that Resident R1 had a sore on her tailbone until it was found the morning of Resident R1's fall on 09/27/2025, and that the area on Resident R1's tailbone did not have the appearance of a skin tear.On 10/09/2025 at 12:36 PM, V5, Licensed Practical Nurse (LPN), stated the CNAs are responsible for checking on residents every two hours and repositioning them. She stated Resident R1 preferred to be up in her geriatric chair and that she sits in it most of the day. She also stated that she did not know how one would be expected to reposition a resident who sits in a geriatric chair.On 10/09/2025 at 1:51 PM, V23, Registered Nurse (RN - Hospice), stated that during Resident R1's initial Hospice assessment on 10/04/2025, she discovered a pressure ulcer on Resident R1's tailbone area that was the size of an egg, 0.1 cm in depth, deeper than skin, and pale in color.Resident R1's Wound Care visit report dated 10/07/2025 documents that Resident R1 had a Stage 2 pressure ulcer in the middle of Resident R1's tailbone measuring 6.5 cm by 5.5 cm by 0.1 cm in depth.On 10/09/2025 at 2:39 PM, V24, Doctor of Nursing Practice (DNP - Wound Care), stated he saw Resident R1 on 10/07/2025 and that the area on Resident R1's tailbone was a pressure ulcer, not a skin tear. By the appearance of the wound, it had developed three to four weeks prior and was not caused by Resident R1's fall on 09/27/2025.

Residents Affected - Few

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:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Arc at Hickory Point

565 West Marion Avenue Forsyth, IL 62535

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)

Federal health inspectors cited ARC AT HICKORY POINT in FORSYTH, IL for a deficiency under regulatory tag F-F0689 during a complaint investigation conducted on 2025-10-14.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Scope/Severity Level G: isolated, actual harm that is not immediate jeopardy.

Actual harm to residents was documented as a result of this deficiency.

This was one of 2 deficiencies cited during this inspection of ARC AT HICKORY POINT.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-15.