Inspection visit

Health inspectionApril 17, 2025

ARC AT HICKORY POINTCMS #1461487 citations on this visit

7 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 7 deficiencies, 2 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain a Do Not Resuscitate (DNR) order, ensure a POLST (physician orders for life-sustaining treatment) form was part of the medical record, and failed to update the care plan after deciding Advance Directives wishes for one (R179) of 24 residents reviewed for Advance Directives on the sample list of 27. Findings include: The facility's Advance Directives policy, with a revision date of 3/2024, documents upon admission residents will be asked about their Advance Directives and a POLST(physician orders for life-sustaining treatment) form will be completed. This policy states a written physician's order is required in response to the resident's Advance Directives and will be included in the resident's care plan. This policy also states that in the event a resident has no Advance Directive(s) relative to CPR (cardiopulmonary resuscitation) the nursing staff will provide emergency and ongoing nursing care and basic life support. On [DATE] at 09:30 AM, R179 stated when he was admitted , he signed an Advanced Directive form and his wishes were to be a Do Not Resuscitate. On [DATE] at 9:30 AM, V16 and V17 confirmed R179's wishes were to be a Do Not Resuscitate. R179's electronic health record documents R179 was admitted to the facility on [DATE]. R179's physician's orders do not include orders for an Advanced Directive. R179's care plan does not include R179's wishes for his Advanced Directives. On [DATE] at 9:23 AM, V3, Registered Nurse, stated, To find a residents code status, we go to the electronic health record, and go to the Advanced Directives under their name, and click on it, and it takes you to their POLST form. If it isn't there, then we go to the code status binder and find it in there. On [DATE] at 1:30 PM, R179's medical record did not contain an Advanced Directive or a POLST form. R179's electronic health record did document R179's code status as a DNR on the profile information section under the resident's name, however, when the Advanced Directive button was pushed, there was not an Advanced Directive uploaded into the system. On [DATE] at 1:30 PM, a code status/POLST binder was on a cart at the nurse's station. This binder did not contain an Advanced Directive or a POLST form for R179. (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 13 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 04/17/2025 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)

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On [DATE] at 12:41 PM, V2, Director of Nursing (DON), stated on admission, R179 stated he wished to be a DNR, and a POLST form was signed and faxed to R179's doctor for his signature. On [DATE] at 1:02 PM, V2 stated she checked, and they hadn't received the POLST back from the doctor yet. V2 stated after a resident and physician signs a POLST form, it gets uploaded into the electronic medical record, and a second hard copy is kept in a binder at the nurses' station for easy access. V2 stated there is no code status form in the binder for R179 currently, and he would be considered a full code and would be given CPR. Event ID: Facility ID: 146148 If continuation sheet Page 2 of 13 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 04/17/2025 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)

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 observation, interview, and record review, the facility failed to identify, assess, intervene, and treat pressure wounds for three (R171, R183, and R1) of four residents reviewed for pressure ulcers from a total sample list of 27 residents. These failures resulted in R171 and R1 developing facility acquited unstageable wounds underneath immobilizers. Residents Affected - Few Findings include: The facility provided Skin Condition Assessment and Monitoring-Pressure and Non-Pressure Policy, dated 4/2025, documents 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 assuring interventions are implemented. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the Certified Nursing Assistant (CNA). Changes shall be promptly reported to the charge nurse who will perform the detailed assessment. If the resident receives a shower, it will be necessary to have the resident stand or be returned to bed to visualize the buttock area and groin. Care givers are responsible for promptly notifying the charge nurse of skin breakdown. Changes in the wound requires physician notification. The resident's care plan will be revised as appropriate, to reflect alteration of skin integrity, approaches, and goals for care. A licensed nurse will observe the condition of a wound with dressing changes and these observations will be documented in the nurse's notes. If observations are acute, the physician, resident and resident's responsible party will be notified and notification will be documented in the medical record. 1a.) R171's Minimum Data Set, dated [DATE], documents R171 is cognitively intact. R171's wound assessment, dated 3/24/25, documents a facility acquired unstageable pressure ulcer on the right calf with an area of .50 centimeters (CM), first identified on 3/21/25. On 4/15/25 at 10:23AM, R171 had an immobilizer on his right leg. On 4/15/25 at 10:23AM, R171 stated he has a wound on his leg from the immobilizer. On 4/16/25 at 11:30AM, R171's wound dressing change was observed on the right posterior calf. The wound size was approximately that of a quarter requiring a daily treatment of Calcium Alginate and a foam boarder dressing. On 4/16/25 at 11:35AM, V5, Wound Nurse, stated R171 developed a stage three wound under an immobilizer while in the facility because the immobilizer was not removed, and that daily skin checks should be completed. On 4/16/25 at 3:00PM, V26, Physical Therapy Assistant, stated daily skin checks should always be done with immobilizers to prevent skin breakdown. 1b.) On 4/15/25 at 10:16AM, R171 stated he has a wound on his buttock and it has been there for a couple of weeks. On 4/16/25 at 11:45AM, R171 stood up with the assistance of V5, Wound Nurse, and displayed an open (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146148 If continuation sheet Page 3 of 13 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 04/17/2025 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)

F 0686 wound on his left buttock, approximately the size of a pencil eraser. Level of Harm - Actual harm On 4/16/25 at 11:47AM, V5, Wound Nurse, stated she did not know R171 had a wound on his buttock, because no one had ever told her about it. Residents Affected - Few R171's medical record has no documentation of R171's buttock wound. 2.) R183's wound assessment, dated 3/24/25, documents R183 admitted to the facility with an unblanchable area of skin on his right buttock that appeared to be a deep tissue injury with an area of .75 CM. R183's wound assessment, dated 4/1/25, documents R183's right buttock deep tissue injury remains with an area of .75CM. R183's wound assessment, dated 4/7/25, documents R183's right buttock deep tissue injury remains a size of .75CM. R183's wound assessment, dated 4/14/25, documents R183's right buttock deep tissue injury remains a size of .75CM. R183's April treatment administration record documents the use of zinc paste for incontinence. On 4/16/25 at 9:30AM, observed a wound the size of a half dollar, with slough covering the wound. On 4/16/25 at 9:09AM, V4, Certified Nursing Assistant (CNA), stated R183 has an open area on his bottom that has been there for at least a week. On 4/16/25 at 9:35AM, V5, Wound Nurse, applied Zinc paste over the wound mashing the paste into the slough and over the open wound bed. On 4/16/25 at 9:40AM, V5, Wound Nurse, stated she had not notified the physician of R183's wound change, nor had she asked for a treatment order for the wound. R183's physician orders, dated 4/18/25, document the first treatment orders for a wound. 3.) R1's hospital discharge records, dated 1/8/25, documents R1 was readmitted to the facility with a right leg immobilizer following inpatient surgery to repair a right distal femur fracture following a mechanical fall at the facility. R1's Physician Orders, dated 1/30/25, documents to perform skin checks under leg immobilizer every shift. R1's Braden Score Assessment, dated 2/6/25, documents R1 is high risk for developing pressure ulcers. R1's current Minimum Data Set (MDS), dated [DATE], documents R1 is dependent on staff for activities of Daily Living. The same assessment documents R1 is severely cognitively impaired. R1's Wound Assessment, dated 2/20/25, documents a facility acquired pressure ulcer on R1's right (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146148 If continuation sheet Page 4 of 13 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 04/17/2025 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)

F 0686 Level of Harm - Actual harm Residents Affected - Few lower extremity measuring 4 centimeters cm x 1 centimeter cm, and depth is unknown. The same assessment further documented moderate amounts of serosanguinous drainage and redness to wound edge. R1's Wound Assessment, dated 4/14/25, documents a facility acquired pressure ulcer on R1's right lower extremity measuring 2 cm x .7 cm x .3 cm (depth) with moderate serous drainage. This wound is documented as unstageable. R1's February 2025 Treatment Administration Record (TAR), does not contain documentation of skin checks on 2/4/25, 2/8/25, 2/9/25, 2/10/25, and 2/14. The facility census documents R1 was in the building on these dates. On 4/16/25 at 1:00 PM, V5, Wound Nurse, stated the facility nurses could have not noticed R1's pressure ulcer developing because it was on back of leg under the immobilizer. V5 further stated she did not review R1's treatment record to see if staff were signing off on skin checks, and was not aware there were days skin checks were not completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146148 If continuation sheet Page 5 of 13 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 04/17/2025 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe transfer by not utilizing two staff members for a mechanical lift transfer as indicated in his plan of care for one (R16) of three residents reviewed for transfers from a total sample list of 27 residents. Findings include: R16's current care plan, last revised 2/5/25, documents R16 requires two staff members for sit-to-stand mechanical lift transfers. R16's Minimum Data Set (MDS), dated [DATE], documents R16 is severely cognitively impaired and is dependent on staff for transfers. On 4/14/25 at 10:48 AM, R16 was connected to a sit to stand mechanical lift hovering over the toilet in the bathroom, while V19, Certified Nursing Assistant, was cleaning R16's bottom after having a bowel movement. V19 transferred R16 off the toilet and to the wheelchair without assistance from another staff member. On 04/15/25 at 10:22 AM, V21, Licensed Practical Nurse, and V22, Licensed Practical Nurse, stated R16 should have two staff members when being transferred with the sit to stand mechanical lift. On 4/16/25 at 10:12 AM, V11, Certified Nursing Assistant, stated sit to stand mechanical lifts require two staff members for transfers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146148 If continuation sheet Page 6 of 13 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 04/17/2025 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)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm Based on observation, interview, and record review, the facility failed to ensure pain medication was effective, available, and provided when pain was present for one (R179) of two residents reviewed for pain on the sample size of 27. These failures resulted in R179 going without pain medication, canceling his doctors appointment due to pain, and reporting pain of 8 out of 8. Residents Affected - Few Findings include: The facility's pain management program policy, dated 4/2025, documents the facility will manage a resident's pain by developing an optimal pain management plan. This policy also documents the facility will use pharmacological and nonpharmacological interventions which will be included in the resident's care plan. R179's Care Plan, dated 4/11/2025, documents R179 is at risk for pain. This care plan includes interventions to administer pain medications and evaluate the effectiveness of pain interventions. On 4/15/25 at 8:59 AM, R179 was lying in bed in a slouched upright position, with the head of the bed slightly elevated. R179 stated, I have to stay in this position or else I am in pain. R179 then attempted to move in bed to reach the breakfast tray, and began to scrunch eyebrows together and grimace. R179's physician order, dated 4/11/25, documents an order for one to two 37.5-325 milligram tablets of Tramadol-Acetaminophen every 8 hours as needed for moderate pain. On 4/16/25 at 8:57 AM, R179 was lying flat on his back in his bed. R179 stated, I hurt all over, but especially in my back. I'd say its 100% hurting. R179's Controlled Substance Proof of Use sheet, dated 4/12/25, documents one tablet of Tramadol-Acetaminophen 37.5-325 milligrams was given on 4/15/25 at 7:00 AM. This sheet documents this tablet as the last dose of this medication. On 4/16/25 at 10:30 AM, V7, Licensed Practical Nurse, stated she just met R179 this morning. V7 stated she was informed by the night shift nurse that R179 came to the facility with an order for Tramadol for pain relief, but he ran out and agency nurses did not request a refill or new orders. V7 stated R179 canceled his appointment with his doctor this morning because he was in so much pain. V7 stated she gave R179 Tylenol this morning, but he is going to need something stronger. V7 stated she is going to reach out to R179's primary doctor today to see if he can give an order for pain relief. V7 stated R179 said he would just lay in a certain position to stay comfortable. On 4/16/25 at 11:15 AM, V16 (R179's granddaughter) stated R179 called her, and V17 (R179's daughter) at 2:00 am and 3:00 am this morning because he was in pain and he couldn't reach his call light. V16 stated they ran out of his pain medication, which had helped with his pain. On 4/16/25 at 2:40 PM, V2, Director of Nursing, confirmed R179 was out of Tramadol/Acetaminophen, and stated the pharmacy dispersed six tablets on 4/11/25. V2 stated R179 rated his pain as an eight out of eight today. V2 stated a prescription should be refilled when there are four doses left. V2 stated the facility did not attempt to refill it until yesterday (4/15/25). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146148 If continuation sheet Page 7 of 13 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 04/17/2025 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** [NAME] Residents Affected - Few Based on observation, interview, and record review, the facility failed to assess, consent, care plan, intervene, and communicate changes to the prescribing physician for two (R16, R50) of five residents reviewed for psychotropic medications out of a sample list of 27 residents. Findings include: The facility provided Behavior Health Services Program Policy, dated 4/2025, documents the purpose of behavioral health management is to establish a system for identifying behaviors and implementing appropriate interventions consistent with the individualized plan of care and to ensure that each resident receives appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. The facility will obtain consent for any new psychotropic medications prior to administration. All interventions attempted including medication administered and the resident's response to medical interventions will be documented. Monitoring of behaviors and effectiveness of interventions will include reviewing resident behaviors, and reviewing the care plan which should include measurable goals, resident responses to therapy, and the rationale for psychotropic medication use with specific targeted behaviors, monitoring for efficacy and or adverse consequences and plans for gradual dose reductions, if appropriate. 1.) R16's Medical Diagnosis List documents a diagnosis of Dementia. R16's Minimum data Set (MDS), dated [DATE], documents R16 does not have any behaviors. The same MDS documents R16 is cognitively impaired. R16's Behavior Tracking task, dated 3/17/25-4/15/25, does not document any behaviors for R16. R16's current care plan does not contain non-pharmacological interventions for R16's behaviors. R16's medical record does not document any behaviors except for yelling out at night on these dates 3/31/25, 4/1/25, and 4/5/25. R16's nurse Progress Note, dated 3/31/25, documents R16 just hollers for staff to respond. R16's Physician Orders, dated 4/14/25, documents a new order for Seroquel 25 milligrams (mg) twice a day for Dementia, and a separate order for Zyprexa 5 milligrams (mg) for anxiousness. R16's Current Physician orders also document to monitor side effects of psychotropic medications every shift, and notify V12, Physician, of increased sedation and lethargy. R16's Nurse Progress Note, dated 4/15/25 at 12:40 PM, documents V28, R16's Family Member, spoke with nurse and stated V28 is concerned about R16 not holding his head up. On 04/16/25 at 10:07 AM, R16 was sitting in a high back wheelchair very lethargic, leaning to R16's left side asleep. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146148 If continuation sheet Page 8 of 13 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 04/17/2025 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/16/25 at 10:10 AM, V10, Physical Therapist, stated in R16's previous therapy notes, R16 can normally stand with a walker and assistance. V10 stated, This a big difference. (R16) normally walks 20 feet with assistance and a walker. (R16) can't even hold himself up. V10 placed a pillow on R16's left side to prop R16 up in the wheelchair. On 04/16/25 at 10:12 AM, V11, Certified Nursing Assistant, stated, Normally, (R16) can bear weight and stand pivot. (R16) is not normally this out of it. On 04/16/25 at 10:42 AM, R16 is sitting in the therapy room in a high back wheelchair with platform foot pedals on chair. R16 is sleeping and not participating in therapy. On 4/16/25 at 11:30 AM, V2, Director of Nursing, stated for the last week, R16 has been more emotional and crying and not sleeping at night. V2 stated R16 was on Zyprexa 2.5 milligrams (mg) before bed for anxiety and Melatonin 5 mg at night for insomnia. V2 stated R16 was not sleeping well, so that's why V12, Physician, changed R16's medications. On 04/16/25 at 11:40AM, V6, Regional Nurse Consultant, stated V6 did an audit last week, and R16's medical chart did not contain an assessment prior to start of the psychotropic medication on 4/14/25. On 04/16/25 at 11:47 AM, V12, Physician, stated R16 starts yelling out if he is in his room alone, if you take him to the nurse's station he sits quietly and doesn't yell. V12 stated he doesn't want R16 zonked out, but wants more control of behaviors. V12 further stated most of R16's episodes are when R16 goes into his room and is alone, so V12 decided to be harsher than normal, and started R16 on Seroquel and increased his Zyprexa. V12 stated no facility staff have contacted V12 regarding R16 since the start of the medications. V12 stated, I told the facility if (R16) becomes too lethargic, I want to be notified so I can adjust the medications. R16's medical record does not contain documentation of physician notification of R16's increased lethargy and decreased functional ability. [NAME] 2.) R50's undated census report documents R50 was originally admitted to the facility on [DATE], and then re-admitted to the facility on [DATE]. R50's undated diagnosis sheet documents the following diagnoses: Fracture of Left Femur, Diabetes Mellitus Type II, Fracture of T11 and T12 vertebra, Chronic Obstructive Pulmonary Disease, Unspecified Atrial Fibrillation, Hyperlipidemia, Pleural Effusion, Anemia, Urinary Device Placement, Ventricular Tachycardia, and Syncope. R50's physician order sheet, dated 2/13/25, documents an order for Mirtazapine 15 milligrams (MG) daily for depression. R50's behavior tracking does not document any signs or symptoms of depression. R50's medical record does not include any diagnoses of depression. R50's undated care plan does not document any diagnosis of depression, behaviors requiring (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146148 If continuation sheet Page 9 of 13 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 04/17/2025 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm depression management (pharmacological nor non-pharmacological) goals for depression management, nor the use of anti-depressants. R50's April 2025 Medication Administration Record documents Mirtazapine 15MG was administered before bed daily. Residents Affected - Few On 4/16/25 at 12:48PM, V6, Regional Clinical Director, confirmed there is no consent, assessment, diagnosis, or documented indication for the administration of Mirtazapine 15MG for R50. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146148 If continuation sheet Page 10 of 13 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 04/17/2025 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to properly store medications by pre-pouring medications and leaving them at the bedside and in the cart, unlabeled, without any identifiers for four (R31, R173, R175, and R185) of four residents reviewed for medication storage from a total sample list of 27 residents. Findings include: The facility Medication Administration Policy, dated 4/2025, documents medications may not be pre-poured. 1.) On 4/15/25 at 10:13AM, R31's medications were left at R31's bedside, R31 stated, I couldn't take them all, but I will. 2.) On 4/15/25 at 10:55AM, R173's medication was sitting at R173's bedside. V18, Family Member, stated, He didn't take his pain medication; it is his Norco. R173's April medication administration record documents Hydrocodone-Acetaminophen Oral Tablet 10-325 MG was administered by V19, Registered Nurse, at 10:17AM. 3.) On 4/15/25 at 9:22AM, R175's medications were left at R175's bedside. 4.) On 4/16/25 at 12:30PM, the 100 A cart was observed with pre-poured medications in a medication cup, with no name or label. V9, Licensed Practical Nurse (LPN), stated the medication was for R185,, and she had gone to therapy, so she was going to give them to R185 after she returned. On 4/16/25 at 12:35 PM, V9, LPN, stated the pills were R185's morning medications, but she could not recall what specific medications were in the cup. R185's April 2025 medication administration record documents the following morning medications include: Amlodipine (blood pressure) 10 milligrams (MG), Lasix (diuretic) 20MG, Losartan (blood pressure) 50MG, Pantoprazole (gastroesophageal reflux disease) 40MG, Spirolactone (diuretic) 25 MG, and Carvedilol (blood pressure) 2.5MG. On 4/17/25 at 8:45AM, V3, Registered Nurse, confirmed he left medications at the bedsides of R31, R173, and R175 on 4/15/25, and he knew he was supposed to watch the residents take the medications. On 4/16/25 at 2:55PM, V2, Director of Nursing, stated she would expect medications to be administered as they are poured, and not left at the bedside, nor in the medication cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146148 If continuation sheet Page 11 of 13 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 04/17/2025 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)

F 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview and record review, the facility failed to have a comprehensive Infection Prevention and Control Program, including infection monitoring and surveillance. This failure has the potential to affect all 63 residents residing at the facility. Findings Include: The facility Infection Prevention and Control Program Policy, dated effective 10/2024, documents the facility will identify, monitor, track and report infections and monitor adherence to infection control practices. Infection surveillance for compliance may include but is not limited to review of laboratory/microbiology reports and results, observing for trends and monitoring to ensure appropriate precautions were initiated as appropriate. Infection Tracking includes but is not limited to completing Infection Tracking Log for all residents with an infection and/or treated with antibiotics, track physician antibiotic prescribing practices as appropriate, monitor for trends by unit/location, clusters of same infection types/organisms, outbreaks, and employee illnesses. The facility Infection Prevention and Control Program Policy documents on line 2. The Infection Control Program meets the guidelines of the US Department of Health and Human Services Centers for Disease Control and Prevention, HCFA, the Occupational Health and Safety Administration, local, state and federal rules. The facility's Long-Term Care Facility application for Medicare and Medicaid, dated 4/14/25, documents there are 63 residents residing in the facility. 1.) On 4/14/25 at 10:00 AM, V1, Administrator, identified V2 (Director of Nursing, DON) as the Infection Preventionist. On 4/14/25 at 10:10 AM, V2 (DON) stated V2 was not the Infection preventionist. V2 stated there was a nurse from another facility (V29) who completes the Infection Prevention and Control Program one day a week. V2 stated V2 has not completed an infection control program, and does not have an Infection Preventionist Certificate at this time. On 4/14/25 at 1:45 PM, V15's current physicians orders document an order for Bactrim Oral Tablet 400-80 MG (Sulfamethoxazole-Trimethoprim) started on 7/13/23. Give 0.5 tablet by mouth in the morning for urinary tract infection prophylaxis. R15's current care plan documents R15 was admitted to the facility on a prophylactic antibiotic to prevent reoccurring UTIs. On 4/16/25 at 2:00 PM, V29, Infection Preventionist, stated V29 started working at the facility last month. V29 stated she is currently working as an Administrator at another facility, so V29 is only able to make it to the facility one day a week. V29 stated she is trying to review progress notes, attend daily meetings, and look at lab results and hospital information. V29 further stated V29 tries to piece things together the best V29 can. V29 stated she is unable to complete staff education because V29 doesn't have time with only being at the facility one day a week; it makes it hard to do the job appropriately. V29 stated she is not aware of any residents in the facility on prophylactic antibiotics. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146148 If continuation sheet Page 12 of 13 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 04/17/2025 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)

F 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete 2. R3's physician order, dated 2/27/25, documents an order to give one 250 milligram tablet of Cephalexin (antibiotic) everyday at bedtime for prophylactic. R3's medical record does not contain an assessment or care plan for the use of a prophylactic antibiotic. On 4/16/25 at 12:45 PM, V6, Regional Nurse Consultant, stated she couldn't find any documents to support the reason R3 is on a prophylactic antibiotic. Event ID: Facility ID: 146148 If continuation sheet Page 13 of 13

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Citations

7 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0578GeneralS&S Dpotential for harm
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
0686SeriousS&S Gactual harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0689GeneralS&S Dpotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0697SeriousS&S Gactual harm
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
0761GeneralS&S Epotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0882GeneralS&S Fpotential for harm
F882 - Infection preventionist
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

FAQ · About this visit

Common questions about this visit

What happened during the April 17, 2025 survey of ARC AT HICKORY POINT?

This was a inspection survey of ARC AT HICKORY POINT on April 17, 2025. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at ARC AT HICKORY POINT on April 17, 2025?

Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate ..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·April 17, 2025