Arc at Hickory Point

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received timely antibiotic therapy for a wound infection, failed to notify the physician of new wounds and obtain treatment orders, and failed to follow Enhanced Barrier Precautions, complete wound assessments and update wound care plans for two of four (R4 and R6) residents reviewed for pressure sores on the sample list of 20. Failing to ensure R4 received timely antibiotic therapy resulted in R4's pressure sore continuing to deteriorate and R4 experiencing severe pain. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to designate a Registered Nurse as a full time Director of Nursing. This failure has the potential to affect all fifty-five residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement fall interventions for one (R4) of three residents reviewed for falls in a sample list of three.

Inspectors wroteBased on interview and record review, the facility failed to treat residents with respect and dignity for one (R76) of three residents (R75, R60, R76) reviewed for respect and dignity in the sample list of 37 residents. This failure resulted in R76 feeling embarrassed and degraded with a low self-esteem after staff continued the incontinence check after R76 stated R76 had notified staff that R76 was continent of urine. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an oxygen cylinder was secured and stored properly for two residents (R71 and R1) in a sample list of 37 residents. Findings Include: On 3/01/2026 at 8:35AM, R71 had a portable oxygen cylinder located on the left side of R71's bed, not secured and not in use by the resident. R71 stated R71 does not use oxygen. On 03/01/2026 at 9:05AM, R1 had a portable oxygen cylinder located by the entry door inside R1's room. R1 stated R1 use to use oxygen and a BiPAP (Bilevel Positive Airway Pressure) machine but no longer uses either. R71's Physician Orders documented on 2/21/26, R71 receives two liters of Oxygen via Nasal Cannula every shift for Shortness of Breath. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure state survey results were accessible and contained all surveys which were completed in the last year. This failure had the potential to affect all 59 residents residing in the facility. On 3/1/2026 at 10:58 AM, R4, R22, R26 and R27 were interviewed for resident council meetings. On 3/1/2026 at 11:50 AM, during the resident council meeting, R4, R22, R26, R27 stated they were unaware of where the state survey inspection results were located. On 3/1/2026 at 12:00 PM, V12 (Receptionist) stated the survey book is located in the foyer in a drawer. V12 pointed to a four-drawer dresser in the foyer. A picture frame propped up on the dresser contained a sign that stated, Survey Results. At that time, the survey book was not located on top of or in the dresser. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to complete wound assessments/measurements at least weekly and implement interventions to prevent wounds for three residents (R1, R6, R36) of five residents reviewed for wounds in a sample list of 37 residents. Findings Include: Facility Skin Condition Assessment & Monitoring - Pressure and Non - Pressure revised on 12/2025 documents a skin condition assessment and pressure ulcer risk assessment (Braden) will be completed at the time of admission/readmission. The pressure ulcer risk assessment will be updated quarterly and is necessary. This also documents that residents identified will have a weekly skin assessment by a licensed nurse. Also, a wound assessment will be initiated and documented in the resident chart when a pressure and/or other non-pressure skin conditions are identified by licensed nurse. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to administer oxygen as ordered by the physician, change oxygen tubing and humidification weekly, and prevent possible cross contamination for four (R19, R36, R51, R58) of six residents reviewed for oxygen on a sample list of 37 residents.

Inspectors wroteBased on interview and record review the facility failed to ensure medications were available by the pharmacy for two (R10, R150) of 16 residents reviewed for medications on the sample list of 37 residents. Findings Include: 1.) On 3/02/2026 at 8:15 AM, R10 stated when R10 was admitted (1/30/26) and readmitted (2/15/26) to the facility, R10's pain medication was not given because the facility did not have it. R10's physician orders dated 1/30/26 documents an order for Oxycodone Hydrochloride 30 milligrams (mg) one tablet by mouth every morning and at bedtime. R10's Medication Administration Record (MAR) for January 2026 documents R10's Oxycodone was not administered and to see progress note on 1/30/2026 and 1/31/2026. R10's progress notes for 1/30/26 at 7:56 PM does not document why the Oxycodone was not administered. [...]

Inspectors wroteA. Based on Observation, Interview and Record Review, the facility failed to implement enhanced barrier precautions and Contact Precautions in accordance with facility policy for two residents (R71 and R61) on a sample list of 37 residents reviewed for transmission-based precautions. This deficient practice had the potential to increase the risk of transmission of multidrug-resistant organisms and communicable infections to other residents and staff. B. Based on observation, interview, and record review the facility failed to appropriately sanitize a glucometer between use on multiple residents for one resident (R33) of one resident reviewed for glucometer sanitization in a sample list of 37 residents. Findings Include: A. Facility Enhanced Barrier and Contact Precautions revised on 12/25 with chronic wounds or indwelling medical devices during high-contact resident care activities. [...]

Inspectors wroteBased on interview and record review, the facility failed to answer call lights in a timely manner for one (R76) of three residents (R75, R60, R76) reviewed for call lights in the sample list of 37 residents. Findings Include:Grievance forms dated December 8 and 28, 2025 and February 3 and 26, 2026, all document residents having to wait extended times for help with various activities. Resident Council Minutes dated February 6, 2026, document six residents attended the meeting and documented staff need to answer call lights quicker. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to assess the ability to self-administer medications for one of one resident (R10) on the sample list of 37 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide clean bedding for one (R43) of 43 residents reviewed for environment on the sample list of 37 residents.

Inspectors wroteBased on interview and record review the facility failed to ensure the right to be free from chemical restraints by failing to assess the need for a psychotropic medication, failing to develop a plan of care for an antidepressant used for insomnia and failing to implement non-pharmacological interventions for insomnia for one (R10) of five residents reviewed for unnecessary medications on the sample list of 37 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately assess wounds in the Minimum Data Set for two residents (R36, R1) of 33 residents reviewed for MDS accuracy in a sample list of 37 residents. Findings Include: R36's Minimum Data Set (MDS) completed 2/18/26 documents R36 was admitted on [DATE]. R36's Wound Clinic Consult dated 2/12/26 documents R36 was admitted with wounds to her bilateral lower extremities and left heel. R36's Medication Administration Record (MAR) for March 2026 includes treatment orders initiated 2/12/26 for treatments to her left heel, bilateral groin, and abdominal fold. On 3/1/26 at 8:45AM, R36 was seated in a recliner in R36's room. R36's left heel was covered by a gauze wrap with yellow staining to the heel area. The dressing was not dated and appeared soiled. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide shaving assistance for one resident desiring to be shaved (R58) of three residents reviewed for shaving in a sample list of 37 residents. Findings Include:R58's Minimum Data Set (MDS) dated [DATE] documents R58 is cognitively intact and dependent on staff for personal hygiene including shaving. On 3/1/26 at 9:40AM, R58 was observed resting in R58's bed. R58 had coarse gray facial hair approximately 1/4 inch long on R58's face and chin. When asked if R58 preferred to be unshaven R58 stated no I like to shave every day. I like to be clean shaven. I've never been one to wear a beard, but I can't do it myself and they tell me they can't do that for me. On 3/2/26, V23 Corporate Registered Nurse (RN) verified it is the facility's policy to offer a shave as often as the resident prefers to be shaved. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pain medication when pain was present and as ordered by the physician for one (R10) of two residents reviewed for pain on the sample list of 37 residents. R10's Pain Care Plan dated 2/2/26 documents R10 has low back pain, migraines, and pain due to a left femur fracture. This care plan includes an intervention to provide pain medication as ordered by the physician. R10's physician orders dated 1/30/26 documents an order for Oxycodone Hydrochloride 30 milligrams (mg) one tablet by mouth every morning and at bedtime for pain and an order for Norco 5-325 mg one tablet every six hours as needed for pain. On 03/02/2026 at 8:15 AM, R10 stated when admitted and readmitted to the facility pain medication was not given because the facility did not have it. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store medications for two (R10, R51) of 24 residents reviewed for environment on the sample list of 37 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify a newly admitted resident as a potential elopement risk and failed to provide supervision and interventions to prevent elopement for one of four (R1) residents reviewed for elopement on a sample list of four. These failures resulted in R1, a severely cognitively impaired resident at risk for falls with impaired safety awareness, leaving the facility unsupervised on foot with no coat or shoes on with outside temperatures below freezing. R1 was found by family members six tenths of a mile from the facility in a restaurant parking lot near two interstates/highways eight hours after the resident was last observed in the facility. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to complete thorough fall investigations, failed to implement fall interventions and failed to supervise high fall risk residents for one (R7) resident out of three residents reviewed for Accidents in a sample list of twelve residents. Failing to provide supervision and implement fall interventions resulted in R7 falling and experiencing pain due to injury from an unwitnessed fall that required emergency services.

Inspectors wroteBased on observation, interview and record review the facility failed to investigate grievances of three (R2, R10, R11) residents out of four residents reviewed for grievances in a sample list of twelve residents.

Inspectors wroteBased on observation, interview and record review the facility failed to document an open wound for one (R2) resident out of three residents reviewed for wounds in a sample list of twelve residents.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination during incontinence care for two (R11, R12) residents out of three residents reviewed for incontinence care in a sample list of twelve residents.

Inspectors wroteBased on interview and record review the facility failed to identify and report an alteration in skin integrity to prevent a pressure ulcer for one (R1) of four residents reviewed for quality of care. This failure resulted in R1 developing a Stage 2 pressure ulcer to the middle of R1's tailbone.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure adequate supervision was provided to prevent a fall for two (R1, R4) of four residents reviewed for accidents. This failure resulted in localized swelling of clotted blood on R1's forehead and a displaced break to R4's left collarbone and localized swelling of clotted blood on R4's forehead.

Inspectors wroteBased on observation and interview, the facility failed to maintain a resident bathroom/shower in clean condition for two residents (R1,R2) of four residents reviewed for environment in a sample list of seven residents. Findings Include:On 9/18/25 at 9:00AM in R1's and 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. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure fall interventions were in place for one (R1) of three residents reviewed for falls on a sample list of seven. This failure resulted in R1 falling and sustaining multiple left-sided rib fractures, a collection of blood in the chest cavity, and a left sided collapsed lung.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify one (R4) resident's Sacral Deep Tissue Injury, failed to obtain and provide treatment orders, failed to updat careplan timely, and failed to implement pressure reducing interventions out of three residents reviewed for pressure ulcers in a sample list of eight residents. As a result of these failures, R4 had pain from her Stage 3 Sacral pressure ulcer which was acquired and worsened under the care of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe transfer for two (R3, R7) residents out of three residents reviewed for transfers in a sample list of eight residents.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wrote[NAME] 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review the facility failed to complete Fall Risk Assessments, post fall neurological assessments, and complete post fall assessments/monitoring for residents. These failures affect three (R1, R2, R3) of three residents reviewed for falls in the sample list of three.

Inspectors wroteBased on interview and record review, the facility failed to implement pressure relieving interventions, assess, monitor, and treat a pressure sore, notify the physician of a reopened pressure sore/worsening pressure sore, and notify the physician of a facility acquired deep tissue injury for two of seven residents (R1, R4) reviewed for pressure sores in the sample list of seven residents. These failures resulted in R1's left elbow pressure sore progressing to an infected stage 4 pressure sore requiring hospitalization, surgery, a wound vacuum, and intravenous antibiotic theray and R4's right heel deep tissue injury deteriorating to an open unstageable pressure sore. The Immediate Jeopardy began on 8/13/24, when R1 obtained an open wound to her left elbow that was not reported to V14 (R1's) Physician/Medical Director. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a staff training program to ensure Certified Nurse Aides completed required training on Communication, Resident Rights, Abuse, Quality Assurance Performance Improvement (QAPI), Infection Control, Compliance and Ethics, and Behavioral Health. This failure has the potential to effect all 55 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure five Certified Nurse Aides (CNA) had a minimum of twelve hours of required education annually. This failure has the potential to affect all 55 residents residing in facility.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician and resident's Power of Attorney (POA) of pressure sores/worsening pressure sores for two of three residents (R1, R4) reviewed for notifications in the sample list of seven residents.

Inspectors wroteBased on interview and record review, the facility failed to review their Infection Control policies annually. This failure has the potential to affect all 60 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility repeatedly failed to document fluid intake and output according to facility policy and residents plan of care, for one of one resident (R156) reviewed for indwelling urinary catheters on the sample list of 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent cross contamination during pressure ulcer/wound treatment for one of two residents (R6) reviewed for pressure ulcers/wounds on the sample 27.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (R2) was treated with respect and dignity of three residents reviewed for respect and dignity in a sample list of five residents. Findings Include: R2's Diagnosis List, updated 3/1/24, includes the following diagnoses: Fracture right Radius, Fall, Atrial Fibrillation, Anxiety, Pelvic fracture, and History of Covid 19. R2's Minimum Data set (MDS), dated [DATE], documents R2 is mildly cognitively impaired. The facility's Incident Log, dated 2/25/24, documents, On 2/25/24 (V9), CNA (Certified Nurse's Aide) was with (V10) CNA (Certified Nurse's Aide) at approximately 9:30PM to 9:45PM. (V9) and (V10) were providing care when (R2) was raising her voice to the aides and started to tell (V9) that (V9) was being difficult. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a significant change in condition and failed to provide supervision following a significant change in condition for one resident (R1) of five residents reviewed for falls and condition change in a sample list of five residents. These failures resulted in R1 falling face first out of bed and sustaining a hematoma to the forehead. Findings Include: R1's Care Plan, revised 2/29/24, includes the following diagnoses: Hemiplegia/Hemiparesis following Cerebral Vascular Accident Nondominant Side, Hypertension, Status Post Coronary Artery Bypass and Graft, Tricuspid Valve Replacement, Hypertrophic Cardiomyopathy. Chronic Obstructive Pulmonary Disease, Aortic Stenosis, Implanted Pacemaker, and Chronic Anticoagulation. R1's MDS (Minimum Data Set), dated 2/25/24, documents R1 is moderately cognitively impaired. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a plan of care for a catheter and monitor urine output after catheter removal for two (R2, R8) of three residents reviewed for catheters on the sample list of eight. This failure resulted in R2 requiring emergency medical treatment where R2 was found to have Urinary Retention, Bacteremia, Acute Kidney Injury, and Sepsis.