Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to complete daily weights, failed to notify the
physician of weight changes, and failed to monitor intake and output for residents with congestive heart
failure for 1 of 1 residents (R5) in the sample of 18 and 1 resident (R65) outside of the sample.
Residents Affected - Few
The findings include:
1. R65's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include acute and
chronic respiratory failure with hypoxia, interstitial pulmonary disease, dyspnea, heart failure, and
hypertension. R65's facility assessment dated [DATE]. R65's facility assessment dated [DATE] showed R65
requires extensive assist of two staff members for most activities of daily living.
R65's October 2022 physician order sheet showed an order started 4/15/22, Daily Weights: Notify NP
(Nurse Practitioner) of 3# gain in 24 hours OR 5# gain in 1 week; please view under wt/vitals tab - NURSE ENSURE THESE ARE COMPLETED AND YOU HAVE COMPARED RECENT WEIGHTS FOR PROPER
NOTIFICATION AND MED ADMINISTRATION.
R65's weights and vitals record for October 2022 showed no daily weight was obtained for R65 for 12 of the
30 days in October 2022. R65's weights showed on 10/16/22 she weighed 187.4 lbs and on 10/17/22 she
weighed 195.4 lbs (an 8 lb weight gain in 24 hours), she weighed 10/21/22. R65's medical record showed
no evidence of physician notification of R65's weight change on 10/17/22.
R65's nurse practitioner visit note dated 10/28/22 showed, Chief Complaint: Acute visit: increase weight,
swelling, CHF (Congestive Heart Failure) . Staff reports that patient has had a 16 lb weight gain within the
last week. She has increase swelling and some shortness of breath . Extremities: . Increased edema to BLE
(bilateral lower extremities), pitting .
R65's care plan initiated on 4/15/22 showed, [R65] has altered cardiovascular status r/t atrial fibrillation,
congestive heart failure, atrial flutter, and hypertension . DAILY WEIGHTS: notify NP of 3 lb gain in 24 hours
OR 5 # in 1 week; please view under weight/vitals tab. NURSE :: ENSURE THESE ARE COMPLETED
AND YOU HAVE COMPARED RECENT WEIGHTS FOR PROPER NOTIFICATION AND MED[ICATION]
ADMINISTRATION .
On 1/19/23 at 10:00 AM, V6 CNA (Certified Nursing Assistant) said she does daily weights. V6 said she
writes the weight on a piece of paper and gives it to the nurse. V6 said the nurse looks at it and if there is a
3 lb difference they have them reweigh the resident.
On 1/19/23 at 10:03 AM, V8 RN (Registered Nurse) said, All CHF (congestive heart failure) patients
(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 5
Event ID:
145906
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
145906
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/19/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Dixon Rehab & Hcc
800 Division Street
Dixon, IL 61021
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
are weighed daily, the weights are usually done by the CNAs. The CNAs report the weight to the nurse and
we put them into the resident's record. We look at the previous weights documented and monitor the
weights to make sure they are not changing, usually everyone on daily weights has standing orders to call
the physician or NP, update them, and see if they have any new orders. When we notify the NP we make a
progress note that shows we notified them and if there were any changes made. The reason for the daily
weights is to monitor the resident's CHF.
On 1/19/23 at 10:21 AM, V2 DON (Director of Nursing) said CHF patients are to be weighed daily by either
the CNA or nurse. V2 said there would be an order in the resident's record for daily weights. Weights are
done to see how much fluid the resident is retaining. At 11:13 AM, V2 said R65's nursing notes should
show documentation about notifying the NP for the weight changes. V2 said the facility had seen that there
are some issues with the weights. V2 said she would expect the NP or physician to be notified of changes
of 3 lbs in a day or 5 lbs in a week.
01/19/23 11:10 AM V9 (Nurse Practitioner) said, The reason for a resident to be on daily weights is to
monitor their fluid status with the CHF. The standard order is to contact us if resident has gained 3 lbs in a
day or 5 lbs in a week. If we are notified of a weight gain we would evaluate the patient and see if they have
any symptoms, such as shortness of breath or peripheral edema. It is important for us to be notified
because the weight change is our first clue that the patient is starting to have a problem.
The facility's policy with revision date of 01/2017 showed, Weight Assessment and Intervention . 2. Weights
will be recorded in the individuals medical record .
2. On 1/19/23 at 9:15 AM, R5 was lying in bed with the head of the bed at 30 degrees. R5 had a stainless
steel cup of ice water sitting on her bedside table. V6 (CNA) was preparing the resident for catheter care.
R5 stated, Don't lay me flat. It's too hard for me to breathe and I panic. I was in the hospital over Christmas
for heart failure and that was scary. I really couldn't breathe. They (facility staff) were keeping track of my
fluids, but I don't think they are doing that anymore. I'm supposed to be a daily weight because of my heart
problems.
R5's Face sheet dated 1/19/23 showed diagnoses to include, but not limited to: congestive heart failure
(CHF), periprosthetic fracture around internal prosthetic knee, generalized muscle weakness, dysphagia,
depression, anxiety, chronic obstructive respiratory disease (COPD), diabetes, and atrial fibrillation.
R5's facility assessment dated [DATE] showed she was cognitively intact; required extensive assistance for
bed mobility, toilet use, and personal hygiene; was totally dependent on staff for transfers; and had an
indwelling catheter.
R5's Physician Order Sheet dated 1/19/23 showed, .1200 ml fluid restriction. 6-2 Nursing, 180 ml. 2-10
Nursing, 180 ml. 10-6 Nursing, 120 ml. Total by Nursing 480 ml. Total given by dietary: 720 ml . Daily weight.
Notify MD/NP of weight gain of > 3 pounds in a day or > 5 pounds in a week .
R5's Weights and Vitals Summary dated 1/19/23 showed R5 did not have daily weights completed on
12/31/22, 1/7/23, 1/13/23, or 1/17/23.
R5's progress notes were reviewed for the dates of missed daily weights and did not show R5 refused to be
weighed.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145906
If continuation sheet
Page 2 of 5
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
145906
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/19/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Dixon Rehab & Hcc
800 Division Street
Dixon, IL 61021
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
R5's Dietician assessment dated [DATE] showed, R5 was on a 1200 ml fluid restriction related abnormal
electrolyte lab results and was readmitted to the facility following hospitalization related to a CHF
exacerbation and fluid overload. The plan was to continue to monitor weights, medications, labs, skin
integrity, and intakes.
R5's January 2023 Medication Administration Record (MAR) showed there was no documentation of the
amount of fluids provided, for R5's fluid restriction, on the evening shift of 1/4, 1/8, 1/13, 1/15, 1/16 and
1/17/23. There was no documentation for R5's Strict I&O order: on the evening shift of 1/8 or 1/17/23.
R5's Monitor - Output History showed that R5 only had 1 entry on 1/18/23. There were no other output
measurements for R5, in the previous 14 days. (R5 should have had a minimum of daily outputs entered
from 1/5/23 - 1/18/23).
R5's Progress Note dated 12/24/22 at 9:32 PM, showed, complaining of SOB (shortness of breath). O2
placed. Felt worse over time. BP 156/67, 73, 23, and 97.6. Unable to get pulse ox despite warming hands
and trying multiple locations and different machines. Resident requested to be sent to ED (emergency
department). Nail beds dusky and face pale and flushed . At 10:08 PM sent to ER.
R5's progress noted dated 12/26/22 at 1:36 AM, showed, admitted to [local hospital] for CHF exacerbation
and fluid/electrolyte overload. In ICU (Intensive Care Unit).
On 1/19/23 at 10 AM, V6 (CNA) said the CNAs usually pass waters to the residents. We keep track of
intakes and outputs (I&O's) if there is an order to do so. We would chart in the electronic medical record.
They don't allow us to document on any paper. If a resident has an order for Strict I & O, then we should be
doing it. I don't think we are tracking R5's I&O. The daily weights are done by the CNAs. We document them
on a paper and give it to the nurse. The nurse reviews the weights. If there is a weight change of 3 or more
pounds, then the nurse will ask us to re-weigh the resident.
On 1/19/23 at 10:21 AM, V2 (DON) said orders are entered for daily weights. The daily weights should be
completed as ordered. If the resident refuses to be weighed, then there will be a note in the progress notes.
Daily weights are completed for residents with CHF to see how much fluid they are retaining. The weights
are used to determine the appropriate interventions for residents and/or diuretic use. R5 has had multiple
CHF exacerbations. The I & O's should be documented in the EMR by the CNAs. The facility doesn't do I &
O for all residents, only those that have an order. I don't think we are doing I & O's for R5. The nurses also
document on the MAR. The nurses and CNAs should be following all the doctor's orders.
The facility's Intake & Output Policy (reviewed 1/17) showed, 1. Recording of intake and output should only
be done if there is an order from the medical practitioner. 2. Staff responsible for recording fluid intake and
output will be notified by the nurse receiving the order . 5. Intake and output will be recorded every shift in
the medical record. 6. The evening shift nurse is responsible to document the 24 hour total intake and 24
hour total output, as ordered, in the MAR.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145906
If continuation sheet
Page 3 of 5
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
145906
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/19/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Dixon Rehab & Hcc
800 Division Street
Dixon, IL 61021
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure catheter care was provided in a
manner to prevent cross-contamination for 1 of 4 residents (R56) reviewed for catheters in the sample of
18.
The findings include:
On 1/19/23 at 9:08 AM, V7 (Certified Nursing Assistant - CNA) performed catheter care on R56. V2
(Director or Nursing - DON) stated, I'll stay and observe the care and get an audit out of the way. R56 was
lying flat in bed. V7 cleansed around R56's groin with no concerns. V7 obtained a clean washcloth to clean
R56's penis and catheter tubing. V7 used the washcloth to cleanse R56's penis from the shaft toward the
meatus. Then V7 cleansed R56's catheter tubing toward the meatus. The urine in R56's catheter bag was
cloudy yellow with milky sediment noted.
R56's Face sheet dated 1/19/23 showed diagnoses to include, but not limited to: schizophrenia, multiple
sclerosis, dysphagia, cognitive communication deficit, generalized muscle weakness, seizures, and
neurodysfunction of the bladder.
R56's facility assessment dated [DATE] showed R56 had severe cognitive impairment; required extensive
assistance from staff with bed mobility, transfers, toilet use, and personal hygiene; and had an indwelling
catheter.
R56's Progress Notes dated 1/16/23 at 4:54 AM, showed, This nurse spoke with a RN at the local hospital.
Resident being discharged with a diagnosis of UTI (urinary tract infection) ., esophagitis, and constipation.
Resident was given 1 gram of Rocephin (antibiotic) and 1 liter of NS (normal saline). Catheter was changed
.
R56's Catheter Care Plan revised 6/2/22 showed, R56 has a catheter related to neuromuscular dysfunction
of the bladder .
On 1/19/23 at 10:13 AM, V2 (DON) said when cleaning the penis, the CNA should wipe from the meatus
down the shaft of the penis. The catheter tubing should be cleaned from the meatus down the tubing. I don't
know why she (V7) didn't do that during the catheter care, she did it correctly when we practiced. The risk
for developing a UTI increases when catheter care isn't performed properly.
Catheter Care, Urinary Policy (reviewed 1/17) showed, The purpose of this procedure is to prevent
catheter-associated urinary tract infections . Steps in the Procedure: . 11. For a male resident: Use a
washcloth with warm water and soap to cleanse around the meatus. Cleanse the glans using circular
strokes from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a
clean washcloth, rinse with warm water using the above technique . 12. Use a clean washcloth with warm
water and soap to cleanse and rinse the catheter from insertion site outward .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145906
If continuation sheet
Page 4 of 5
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
145906
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/19/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Dixon Rehab & Hcc
800 Division Street
Dixon, IL 61021
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review the facility failed to ensure soiled gloves were removed
when providing care to prevent cross contamination for 2 of 18 residents reviewed for infection control in the
sample of 18.
Residents Affected - Few
The findings include:
1. On 1/17/23 at 6:13 AM, V4 and V5 CNA's (Certified Nursing Assistants) approached R119 in bed. She
was positioned on her left side with a wedge. V5 removed the covers and began to remove the soiled
incontinence brief. After removing the brief, with gloved hands, V5 began peri care with washcloths and
towels. Once she completed care, she reached into her pocket with the soiled gloves, and grabbed a roll of
bags and tore one off. After opening the bag, she placed the soiled linens in the bag. V5 continued to assist
with placing a clean incontinence brief on R119 and positioning her in bed. After V5 was done providing
care she removed her soiled gloves.
2. On 1/17/23 at 6:21 AM R34 was lying in bed. V4 approached her and sat her up to the edge of the bed.
V4 and V5 each with gloves on, assisted R34 to stand up to her walker using a gait belt. R34 had a visibly
soiled brief with feces and urine. She ambulated with her walker as V5 was holding up the back of the
soiled brief to prevent it from falling. Once in the bathroom, R34 was seated on the toilet and V5 removed
the soiled brief and clothing. With the same soiled gloves she continued to remove the gait belt, placed
clean clothing on R34, re-applied the gait belt, combed her hair, and placed her dentures. After R34 was
finished using the toilet, V5 stood her up and washed her buttocks and washed away visible feces. V5
continued with the same gloves to pull up R34's pants before removing the soiled gloves.
On 01/17/23 at 6:40 AM, V4 stated clean gloves should be applied when walking into a resident's room,
and then changed when going from dirty to clean surfaces, removing soiled linens from the bed, and after
removing soiled incontinence briefs.
01/18/23 01:40 PM, V2 DON (Director of Nursing) stated the correct process for glove use is to change
between soiled surfaces. And hands should be washed after discarding the soiled gloves.
The facility's infection prevention and control manual Standard precautions, Gloves policy documents the
purpose is to 1. To reduce the possibility that healthcare workers will become infected with microorganisms
that are infection residents. The policy 3. Sterile gloves and examination gloves are removed: a. as soon as
practical when contaminated. d. Before touching uncontaminated surfaces or other areas of the same
resident's body that may by contaminated.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145906
If continuation sheet
Page 5 of 5
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
3 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.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the January 19, 2023 survey of DIXON REHAB & HCC?
This was a inspection survey of DIXON REHAB & HCC on January 19, 2023. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at DIXON REHAB & HCC on January 19, 2023?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
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.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.