Health inspection·November 6, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident (R1) was free from physical abuse of (R2) for two of three residents (R1, R2) reviewed for abuse in the sample of 7. The findings include: The State Report dated 10/27/24 for R1 showed, V1 (Administrator) was notified that R1 stated R2 smacked him. Investigation initiated. Staff attempting to assist in this situation and R2 kicked and struck the CNA (Certified Nursing Assistant). Residents separated from one another. R2 refused to let staff near him. R2 being sen out for further evaluation. Family of both residents notified. Provider notified. Police notified. Investigation completed. V9 (Laundry Aide) stated, when I was returning from break, R2 was at the door asking me for help to open the door so he can get out of his room, his roommate hit him. V5 stated that R2 has had a change in condition; the resident is currently experiencing altered mental status and aggressive behavior. He recently moved to the current room. This nurse was notified that the resident and his roommate were in the room together and there were words said to each other. Screaming was heard by CNA staff and when CNA staff entered the residents' room the roommate (R1) said he was slapped across the face. The residents were immediately separated. When CNA staff attempted to intervene, R2 began kicking and swinging his fists at CNA making contact several times before the CNA was able to get out of the room. V1 and V2 (DON/Director of Nursing) met with R2's daughter who insisted that this is not normal behavior for her father and she was extremely upset the day this happened. Upon completion of this investigation it has been determined that there is no visual proof that R1 was slapped across the face, no witness to this encounter and considering R2's altered mental status and change in condition, it is determined that this was the result of the newly diagnosed infection and an isolated incident. On 11/6/24 at 10:16 AM, V4 (R1's daughter/POA - power of attorney) stated the facility moved a new man into her fathers room and introduced him (R2) to R1. V4 stated R1 told her he was talking to R2 and R2 grabbed his hat. The man (R2) said it was his hat and said R1's coat was his too. The man (R2) pushed R1 and R2's hand went to R1's face. R1 was startled; he told the people there. On 11/6/24 at 11:07 AM, V2 (DON) stated she was notified of an altercation; R2 struck R1. The CNAs separated them and the nurse was down there as well. R2 was hitting the CNAs, that is what one CNA reported. V2 stated R2 did not have any behaviors before this that she was aware of. V2 stated both residents have some dementia/cognitive impairment. V2 stated R2 never resolved his pneumonia and had a urinary tract infection when this occurred. On 11/6/24 at 11:39 AM, V6 (RN/Registered Nurse) stated R1 and R2 were both in wheelchairs facing (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 11/06/2024 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)