Health inspection·February 26, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two staff members completed a mechanical lift transfer for one of three (R1) residents reviewed for accidents in a sample list of three residents. This failure resulted in R1 injuring R1's leg during a transfer and suffering a femur fracture requiring hospitalization and retrograde nailing. Findings include: The Facility's Mechanical Lift Policy, dated 5/26/2009, documents when using a mechanical lift for transfers two staff members need to be present. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is severely cognitively impaired. R1's care plan, dated 11/27/24, documents R1 transfers with a mechanical lift and assistance of two people. R1's Nurse Progress Note, dated 1/6/25 at 2:30 AM, documents R1 began yelling to get up around 12:15 AM, V6, Certified Nursing Assistant, assisted R1 out of the bed with a mechanical lift and transferred R1 to her wheelchair. The Note documents R1 was brought out to the nurses' station around 1:00 AM and R1 began yelling and screaming that her leg hurt. V7, Licensed Practical Nurse, documented R1 was unable to move her right lower extremity independently and it appeared displaced. The Note documents when given medications around 7:00 PM, R1 was in normal mood without pain. There was no trauma or injury to affected area, no recent fall, and no popping sounds within the shift. V7 further documented 911 was called around 1:30 AM, and R1 was sent to the emergency room. R1's x-ray report, dated 1/6/25, documents oblique displaced fracture of the distal right femur. The Hospital Discharge summary, dated [DATE], documents R1 underwent a retrograde nailing on 1/6/25 to repair R1's fractured femur. On 2/26/25 at 10:35 AM, V6, Certified Nursing Assistant, stated on 1/6/25, R1 was yelling out that she needed to go to the bathroom. Using the mechanical lift (sit to stand lift), V6 assisted R1 up out of the bed and transferred her to her wheelchair. V6 stated R1 was complaining of pain once she got in the wheelchair. V6 stated she took R1 to the nurse's station where the nurse assessed R1 and sent her to the emergency room because her right leg did not look right. On 2/26/25 at 12:50 PM, V7, licensed Practical Nurse, stated she came into work at 6:00 PM on (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 2 Event ID: 146148 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 146148 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 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)