Health inspection·January 15, 2025

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 interview and record review the facility failed to identify an area of pressure before becoming a stage 3, failed to have a wound evaluated by a wound care professional and failed to assess and document an area of skin breakdown. This applies to one of three residents (R1) reviewed for pressure in the sample of three. This failure resulted in R1 sustaining a stage 3 pressure ulcer with 90% slough and necrotic tissue to her sacrum. Residents Affected - Few The findings include: The facility face sheet for R1 shows she was admitted to the facility on [DATE] with diagnoses to include spinal stenosis, Type 2 Diabetes Mellitus, abnormalities of gait and mobility and urge incontinence. The facility assessment dated [DATE] shows R1 to have severe cognitive impairment and requires maximal assistance with her activities of daily living. The same assessment shows R1 was admitted to the facility with a risk of developing a pressure injury but did not currently have any. The facility's electronic health record census tabs shows R1 was discharged to another facility on 12/3/24. On 1/15/25 at 11:00 AM, V4, R1's Power of Attorney (POA) said her mother was at the facility for rehab after back surgery and then she was to be transferred to another facility for long term care. V4 said she was told by the facility staff that R1 had a stage 2 pressure injury to her sacrum. V4 said she was aware of the pressure injury and had asked for R1 to be seen by a wound care professional, but that had never happened. V4 said when R1 arrived at the new facility, that facility's wound care provider happened to be in the building, and saw R1 that day. V4 said the provider said there was no way the pressure injury was a stage 2 due to all the slough (devitalized tissue) that was present. V4 said the provider debrided the wound and it was determined to be a stage 4 pressure injury with a small amount of bone being visualized. On 1/15/25 at 9:45 AM, V1 Administrator and V2 Director of Nursing said V2 was in charge of wound care when R1 was a resident in the facility. V2 said when a resident gets a new wound it is assessed by her and a treatment is ordered for the care. A wound care professional is contracted by the facility to see all wounds, but the day R1's wound was discovered, she was also diagnosed with COVID-19 and was placed on isolation. V2 said the wound care professional would not see her while she was on isolation for COVID-19. V2 then said that after R1 was off of isolation, it was the Thanksgiving holiday and the wound care professional was not working. V2 said she continued with treatment of the wound and did not feel the wound was getting worse and was improving. V2 said the wound was a stage 3 pressure injury when it was found. The wound was filled with slough. V2 said she tried to get R1 seen by the local wound care clinic but no appointments were available. V1 and V2 said R1's Physician was aware of the wound and had signed orders for the care of the wound. (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 01/15/2025 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)