Health inspection·December 21, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm nectar consistency. V8 stated they have vanilla shakes this week. V8 stated the thickener is in the bottom of the carton. V8 stated to activate the thickener the carton has to be shaken really well and then the liquid inside will be a nectar thick consistency. V8 opened a supplement carton without shaking it and poured it into a cup and it appeared thin. V8 showed the bottom of the carton and stated, if you look at the bottom of the carton that is where the thickener is; that is why it needs to be shaken real well. Residents Affected - Few The Face Sheet dated 12/19/23 for R13 showed medical diagnoses including cerebral infarction, dysphagia, facial weakness, vascular dementia, cognitive communication deficit, and weakness. The Physician's Orders dated 12/20/23 for R13 showed on 11/28/23 a swallow evaluation was to be completed for possible advancement/upgrade of diet; 7/18/23 - Regular diet, pureed texture, nectar thick fluids consistency. Resident prefers straws or sippy cup for all drinks for diet; and 6/30/23 - health shake three times per day. The Nurse Practitioner Notes dated 12/18/23 - addendum: Discussed with daughter/POA (power of attorney) options of non-oral nutrition versus continuing a pureed diet. At this time POA would like to continue feeding R13 the pureed diet; we discussed the risks versus benefit with this choice including risk of pneumonia or death. She verbalized understanding. The Nurse Practitioner note dated 12/15/23 showed, Chief Complaint - patient seen today after reviewing swallow study results. Assessment/Plan - aspiration of food. Swallow study done to assess whether we could advance R13's diet. R13 has severe dysphagia with silent aspiration of thick liquids during the swallow study with significantly increased risk of aspiration after the swallow with all remaining consistencies due to deep penetration without clearance with liquids and significant residue in the pharynx with all trialed consistencies. Given the patient's limited awareness also increases patient's risk of aspiration of residue after the swallow increased material in the trachea after some trials and suspicious of further aspiration. The Care Plan dated 9/6/23 for R13 showed, R13 is on a general diet with puree texture and nectar thick liquids. R13 is to have a house shake TID (three times per day) for malnutrition. R13 has a swallowing problem related to coughing or choking during meals or swallowing medication. R13 failed the swallow study. Date Initiated: 12/19/2023; Revision on: 12/19/2023. The resident will have clear Lungs, no signs and symptoms of aspiration through the next review date. The resident will have no choking episodes when eating through the review date. All staff to be informed of resident;s special dietary and safety needs. Diet to be followed as prescribed. Instruct resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly. Monitor for shortness of breath, choking, labored respirations, lung congestion. Monitor/document/report to nurse/dietitian and medical doctor PRN (as needed) for difficulty swallowing, holding food in mouth, prolonged swallowing time, repeated swallows per bite, coughing, throat clearing, drooling, pocketing food in mouth. Keep head of bed elevated 45 degrees during meal and thirty minutes afterwards. The facility's Diet and Nutrition Care Manual (2021) showed, caregivers and staff should follow guidelines for safe feeding for individuals with dysphagia as follows: Assuring foods and fluids are of the appropriate texture/consistency Liquids for dysphagia - thickened liquids move more slowly through the mouth and esophagus and allow better control of the swallow than thin liquids. Each individual with dysphagia should receive the least restrictive fluid order possible and the appropriate thickness of liquid. Fluid intake and hydration status should be monitored and evaluated, with changes in the plan of care as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145906 If continuation sheet Page 2 of 6 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 12/21/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm On 12/21/23 V1 (Administrator) presented a document from R13's physician that was dated 12/20/23 with an order stating supervision was not needed when drinking because R13 was going to aspirate with/without supervision. The facility consulted the physician after the concern was brought forward on 12/19/23 that R13 was on thickened liquids, with a drink in her room that was not the right consistency and she had no supervision provided. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145906 If continuation sheet Page 3 of 6 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 12/21/2023 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** 2. On 12/20/23 at 9:39 AM, V12 CNA (Certified Nursing Assistant) and V4 CNA went into R62's room with the mechanical lift device. R62 was sitting in a reclining padded wheelchair with a catheter drainage bag in a dignity bag under his chair. V4 grabbed the drainage bag and placed it in R62's lap and stood back to control the lift device. V12 picked up the drainage bag from R62's lap and attached it to the mechanical lift sling and V4 started to lift R62 from the chair, V12 grabbed the drainage bag to hold onto it during the rest of the transfer as he guided the sling and they transferred R62 to the bed. V12 CNA stated catheter drainage bag should not go on the residents lap for infection control reasons. V12 and V4 did not state the drainage bag should be kept below the level of the resident's bladder. On 12/20/23 at 9:58 AM, V2 DON (Director of Nursing) stated the catheter drainage bag should be below the level of the bladder or opening for a resident with a suprapubic catheter to prevent backflow of urine and an infection. The catheter drainage bag should not be on the resident's lap for the same reason and infection control. The Face Sheet dated 12/20/23 for R62 showed medical diagnoses including schizophrenia, multiple sclerosis, muscle weakness, urinary tract infection, depression, oropharyngeal dysphagia, cognitive communication deficit, and neuromuscular dysfunction of the bladder. The Care Plan printed on 12/20/23 for R62 with a revision date of 7/22/22 showed, R62 has a catheter related to neuromuscular dysfunction of the bladder. Position catheter bag and tubing below the level of the bladder and away from entrance room door or covered with a dignity bag. The facility's Catheter Care, Urinary policy (1/2017) showed, the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine tubing and drainage bag from flowing back into the urinary bladder. Use standard precautions when handling or manipulating the drainage system. Based on observation, interview, and record review the facility failed to ensure an indwelling catheter bag and tubing were changed as ordered and failed to ensure a catheter drainage bag was kept below the level of the bladder for 2 of 2 residents (R280 & R62) reviewed for catheters in the sample of 19. The findings include: 1. R280's computerized face sheet printed 12/20/23 showed an admission date of 12/8/23 and diagnoses including but not limited to traumatic subarachnoid hemorrhage, aphasia (difficulty speaking), neurogenic bladder, and dysphagia (difficulty swallowing). R280's facility assessment dated [DATE] showed no severe cognitive impairment and staff assistance required for eating, hygiene, and dressing. R280's December 2023 physician order sheet showed an order to change the catheter drainage bag at the night shift every Sunday dated 12/8/23. On 12/19/23 at 9:43 AM, R280 was seated in a wheelchair in her room with a catheter drainage bag hooked underneath and inside a dignity bag. The catheter tubing was visible and had a cloudy, white dried substance inside of it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145906 If continuation sheet Page 4 of 6 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 12/21/2023 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 On 12/20/23 at 11:44 AM, R280 was in her wheelchair in her room and the catheter tubing still showed the dried white substance. The urine in the tubing was visible and had a thick, clumpy sediment in it. On 12/20/23 at 12:28 PM, V10 (Licensed Practical Nurse) inspected R280's catheter tubing and took the drainage bag out of the dignity cover. V10 said the tubing needs to be changed because of the sediment. V10 noted the date on the drainage bag was 11/21 (30 days ago and prior to admission). V10 said bag is well overdue too and the 11/21 represents the last time the bag was changed. V10 said catheter tubing and bags need to be changed as ordered. There is the potential for urinary tract infections, blockage, and odors to develop if it is not done. On 12/21/23 at 10:05 AM, V2 (Director of Nurses) stated catheter bags and tubing need to be changed as ordered to prevent infections and any potential systemic kidney issues. Nurses should always be following physician orders correctly. Residents are at risk for a decline in health and not getting the full effect of prevention. It is a normal standard of care. R280's Treatment Administration Record (TAR) was reviewed and showed staff were documenting the catheter bag changes being done each Sunday on the evening shift. The facility was unable to provide an explanation of the discrepancy between the catheter bag last changed date of 11/21 and the documentation on the TAR. The facility's Catheter Care, Urinary policy review dated 1/2017 states under the changing catheter section: Catheters will be changed per medical practitioner order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145906 If continuation sheet Page 5 of 6 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 12/21/2023 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 PPE (personal protective equipment) was worn in a manner to prevent cross contamination for 1 of 1 resident (R280) reviewed for infection control in the sample of 19. Residents Affected - Few The findings include: On 12/19/23 and 12/20/23, R280 had a PPE bin outside her door. There was a large sign on the wall by the door that said, STOP Enhanced Barrier Precautions. The signage had illustrations to show gloves and gowns must be worn when inside the room. The sign clearly stated gowns to be worn when high-contact resident care activities were performed. The care activities included but were not limited to: urinary catheters and feeding tubes. On 12/20/23 at 12:28 PM, V10 (Licensed Practical Nurse-LPN) entered the room and flushed R280's feeding tube. V10 changed R280's catheter drainage bag and tubing. V10 donned and doffed gloves appropriately throughout the cares but did not wear a gown at any time. On 12/20/23 at 1:11 PM. V11 (Infection Control Preventionist) stated R280 is on enhanced barrier precautions. It is a type of isolation for residents with devices like feeding tubes, catheters, wounds, and such. It is to prevent the spread of infections. It is a preventative based isolation. Gowns and gloves are to be worn for anyone providing care. Contamination can spread if the proper PPE is not worn. V10 (LPN) was present during the interview and stated she should have had a gown on during the feeding tube and catheter procedures. The facility's undated Infection Prevention and Control Manual-Enhanced Barrier Precautions policy states: Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organism (MDROs) in nursing homes. High-contact resident care activities where a gown and gloves should be used include: Caring for or using an indwelling medical device. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145906 If continuation sheet Page 6 of 6