Health inspection·October 19, 2023

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 stop attempts of inserting a urinary drainage tube after the resident refused it's insertion. The facility also failed to document the attempts of inserting the urinary drainage tube. This applies to one of three residents (R1) reviewed for resident rights in the sample of 8. The findings include: The facility face sheet for R1 shows diagnoses to include abscess of buttock, type 2 diabetes, obesity, depression and anxiety. The facility assessment dated [DATE] shows R1 to be cognitively intact and required assistance of one staff for activities of daily living. On 10/18/23 at 4:45 PM, R1 said she was a resident in the facility for wound care. R1 said her wound was not healing and the staff were having a hard time keeping the dressing attached to her, so a urinary drainage tube was ordered on 10/4/23. R1 said she agreed to the tube but after 3 attempts to insert were not successful, she asked the staff to stop and they did not, they kept trying. On 10/19/23 at 9:34 AM, V6 LPN (Licensed Practical Nurse) said she was the nurse who first attempted to insert a urinary drainage tube into R1. V6 said she had 3 CNA's (Certified Nursing Assistants) in the room with R1 to help hold her legs open and to hold up R1's abdominal folds. V6 said R1 was tense about the procedure but agreed to it. V6 said she was having trouble getting the drainage tube inserted and had given it 3 attempts when R1 asked her to stop trying. V6 said she sent one of the CNA's to go get another nurse to attempt inserting the drainage tube. On 10/19/23 at 9:45 AM, V7 RN (Registered Nurse) said she was asked by a CNA to come help insert a urinary drainage tube into R1. V7 said she grabbed some supplies and went to R1's room. V7 said R1 was agreeable to me trying to put in the drainage tube, but after my second attempt she yelled for me to stop. V7 said she was not aware R1 had asked V6 to stop trying to insert the drainage tube. On 10/19/23 at 9:51 AM, V12 CNA said she was helping to hold R1's legs so a urinary drainage tube could be inserted. V12 said after V6 tried 3 times, R1 yelled for her to stop. V12 said V6 told another staff to go get V7 to help. V12 said V7 came into the room and attempted twice to insert the drainage tube and then R1 yelled stop. On 10/19/23 at 10:04 AM, V11 CNA said she was helping to hold R1's legs while the nurses were trying to insert a urinary drainage tube. V11 said V6 attempted 3 times to insert the tube and then V11 heard R1 tell her to stop. V11 said a second nurse (V7) then came to help and attempted two more (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: 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 10/19/2023 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)