Health inspection·November 23, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to prevent pressure injuries for residents at risk for pressure, failed to initiate treatment orders when pressure injury was found, failed to monitor a pressure injury for signs and symptoms of infection for 2 of 4 residents (R1, R3) for pressure in the sample of 4. This failure resulted in R1 developing a Stage 3 pressure injury to her right heel that became infected and R3 developing two Stage 2 pressure injuries to his sacrum. Residents Affected - Few The findings include: 1. R1's Nursing admission data collection dated 10/3/24 shows R1 was admitted on [DATE] due to hysterectomy with bladder sling, no impaired skin integrity, abdominal area has 3 small incision sites. On 11/23/24 at 8:47 AM, R1 was sitting up in a wheelchair at the dining room table eating breakfast. R1 had heel protective boots on both feet and a mechanical lift sling underneath her. R1 said she was doing ok and had the boots on because her foot hurt her. On 11/23/24 at 9:20 AM, V3 Registered Nurse was in R1's room, just finishing wrapping R1's heel with a gauze dressing. V3 said R1 has an unstageable pressure wound to her right heel. V3 said the wound started off as a deep tissue injury and then the area turned black and fell off. V3 said it got infected and R1 was put on antibiotics. V3 said now it is a large area on her heel with white and yellow slough and R1 is seeing the wound doctor now. V3 said when R1 was admitted she was able to stand and pivot and now R1 is transferred with a mechanical lift because she is unable to bear weight on the right foot. V3 said R1 is alert and oriented to self, place, but has some developmental delays so it takes a little bit for her to make her needs known. On 11/23/24 at 10:06 AM, V2 Director of Nursing said she is the acting wound nurse right now. V2 said R1 was sent to see a wound doctor at the local hospital when her wound started getting worse and was looking visibly bigger. V2 said not all residents with pressure injuries see the wound doctor only those whose wounds that the medical doctor think needs more care. V2 could not recall if R1's wound became infected. On 11/23/24 at 11:30 AM, R1 was in bed with heel boots in place. R1 said her foot hurt a little right now, but not like it did at first. R1 said she doesn't like to have a sore foot. On 11/23/24 at 12:34 PM, V2 said a Certified Nursing Assistant mentioned to her that R1 had something on her heel and the nurse on duty did a change in condition report (SBAR). V2 said when she first assessed R1's wound on 10/19/24 (during the weekly pressure ulcer assessments), it was a dark brown/purple area to the right heel and was not open at the time. V2 said she notified the doctor and got (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 3 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 11/23/2024 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)