Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Dixon Rehab & Hcc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and high risk for pressure injuries developed a stage 3 pressure ulcer due to the facility's failure to identify and manage the wound appropriately. Despite the resident's risk factors and a request for professional evaluation, the wound was not seen by a wound care professional due to COVID-19 isolation and holiday scheduling. The facility's documentation was inconsistent, and the wound progressed to a stage 4 upon transfer to another facility.
A facility failed to prevent and manage pressure injuries for two residents, leading to a Stage 3 infected heel wound for one and two Stage 2 sacral wounds for another. Delays in treatment orders, inadequate monitoring, and poor communication contributed to the worsening of these conditions, despite existing interventions and policies.
A resident in an LTC facility was allegedly slapped by a new roommate, who exhibited aggressive behavior due to a change in condition, including altered mental status and infection. The incident also involved the resident kicking and striking a CNA. Both residents had cognitive impairments, and the facility's investigation concluded the incident was isolated and linked to the aggressor's medical condition.
A resident with multiple health conditions experienced significant weight loss, which was not accurately assessed or addressed by the facility. Despite being on a diet with increased protein, the resident continued to lose weight, and the dietitian did not physically assess the resident, relying on incorrect information. The recommended increase in liquid protein was not reflected in the physician's orders, indicating a lack of communication and implementation of necessary interventions.
A resident with severe cognitive impairment and a history of falls experienced multiple falls while attempting to go to the bathroom unassisted. Despite being identified as a high fall risk, the facility's interventions, such as reminders and call lights, were ineffective due to the resident's dementia. The resident sustained injuries, including a hip fracture requiring surgery, highlighting the inadequacy of the fall prevention measures in place.
A resident experienced severe pain after hip surgery due to the facility's failure to update and administer the correct pain medication regimen as per hospital discharge orders. The resident's outdated pain medication order was not revised, leading to inadequate pain management despite evident distress.
A dietary aide in an LTC facility failed to wash hands between handling dirty and clean dishes, risking cross-contamination for 89 residents. The dietary manager confirmed the requirement for handwashing between tasks, as outlined in the facility's policy.
The facility failed to properly assess and treat pressure ulcers for several residents, leading to deficiencies in care. A resident with a stage 3 coccyx ulcer did not receive the prescribed treatment, and another with a stage 2 ulcer was found without a dressing. Documentation gaps and delayed treatment orders were also noted, contrary to the facility's pressure ulcer prevention policy.
A facility failed to perform daily weights for a resident with CHF as ordered. The resident, with multiple health conditions including heart failure and chronic kidney disease, had a physician's order for daily weights. However, records show numerous missed weight recordings over several months. The DON confirmed the importance of daily weights for CHF residents to monitor for fluid overload, as per facility policy.
A resident with a stroke-related impairment did not receive necessary passive range of motion exercises or have a splint applied to her contracted hand, as required by her care plan. Staff were unaware of her needs, assuming she preferred to exercise independently, despite her inability to move her left side. This oversight contradicts the facility's policy to maintain optimal physical function.
A resident with a history of depression and self-harm behaviors did not receive timely psychiatric services as ordered. Despite a Nurse Practitioner's directive for immediate psychiatric evaluation due to increased depression, the consultation was delayed by seven days. The delay was attributed to a lack of communication and the psychiatric provider's unavailability, highlighting a failure to adhere to the facility's policy for individualized mental health interventions.
A resident was found with eight pills on her bedside table without a nurse present, contrary to the facility's medication administration policy. The resident claimed she took the pills after breakfast, although the RN had already administered her morning medications. The DON confirmed that leaving medications in a resident's room is against facility practice, as it prevents ensuring the medication was taken.
A facility failed to limit the use of PRN psychotropic medications for a resident, as required by regulations. The resident's orders for Haloperidol Lactate and Lorazepam lacked the necessary stop dates, and the facility did not comply with the 14-day limit for PRN antipsychotic medications. The DON confirmed that orders should include a stop date and be limited to 14 days unless extended by a physician.
Failure to Manage Pressure Ulcer Progression
Penalty
Summary
The facility failed to identify and appropriately manage a pressure ulcer for a resident, resulting in the development of a stage 3 pressure ulcer with 90% slough and necrotic tissue on the resident's sacrum. The resident, who had severe cognitive impairment and required maximal assistance with activities of daily living, was admitted with a risk of developing pressure injuries but did not have any upon admission. Despite the resident's high risk due to conditions such as spinal stenosis, Type 2 Diabetes Mellitus, and incontinence, the facility did not adequately monitor or document the skin breakdown. The resident's Power of Attorney (POA) was informed of a stage 2 pressure injury, but upon transfer to another facility, it was determined to be a stage 4 pressure injury. The facility's Director of Nursing (DON) and staff failed to have the wound evaluated by a wound care professional due to the resident's COVID-19 isolation and subsequent holiday period. The wound care professional contracted by the facility did not see the resident, and the facility's staff continued treatment without professional evaluation, believing the wound was improving. The facility's documentation was inconsistent, with no evidence of wound measurement or monitoring from late September to mid-October, despite orders for wound care. The facility's policy required weekly wound assessments, but the resident's wound was not properly assessed or documented, leading to a significant oversight in care. The facility's failure to adhere to its wound care policy and ensure timely professional evaluation contributed to the progression of the pressure ulcer.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to prevent and adequately manage pressure injuries for two residents, leading to significant health issues. One resident, admitted for a hysterectomy with no initial skin integrity issues, developed a Stage 3 pressure injury on her right heel. The injury began as a deep tissue injury, progressed to an unstageable wound, and became infected. Despite the presence of heel protective boots and a mechanical lift sling, the wound worsened over time, with the resident experiencing pain and requiring antibiotics and wound doctor consultations. The facility's documentation showed delays in treatment orders and inadequate monitoring of the wound's progression. Another resident developed two Stage 2 pressure injuries on the sacrum, which were not initially reported or treated by the staff. The resident was at risk for pressure injuries due to decreased mobility, incontinence, and other factors, and had interventions in place such as a low air loss mattress and regular repositioning. However, the redness and open areas on the sacrum were not addressed promptly, and the staff failed to apply necessary creams or report the condition until it was observed by a surveyor. The facility's policies on pressure ulcer prevention were not effectively implemented, as evidenced by the lack of timely intervention and monitoring for both residents. The documentation and communication between staff and medical professionals were insufficient, contributing to the worsening of the residents' conditions. The facility's failure to adhere to its own pressure ulcer prevention policy resulted in preventable pressure injuries and inadequate care for the affected residents.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident (R1) from physical abuse by another resident (R2), as evidenced by an incident where R2 allegedly slapped R1. The incident occurred after R2, who had recently moved into R1's room, exhibited aggressive behavior due to a change in condition, including altered mental status and a newly diagnosed infection. During the altercation, R2 also kicked and struck a CNA who attempted to intervene. Despite the lack of visual proof or witnesses to the slap, the facility's investigation concluded that the incident was an isolated event linked to R2's medical condition. Interviews with staff and family members revealed that R2 had not previously exhibited such behaviors, and both residents had some level of cognitive impairment. R1's daughter reported that R2 had claimed R1's belongings as his own, leading to the physical altercation. Staff members, including the DON and nurses, confirmed the altercation and noted R2's aggressive behavior towards the CNA. R1's care plan indicated he was social and enjoyed interacting with others, while R2's care plan noted his cognitive impairment but did not document any prior behavioral issues. The facility's policy on abuse prevention and prohibition emphasizes that residents must not be subjected to abuse by anyone, including other residents. The policy defines willful actions as deliberate, regardless of intent to harm. In this case, R2's actions were considered deliberate due to his cognitive impairment, but the facility attributed the behavior to his medical condition and deemed it an isolated incident. The report highlights the need for careful monitoring and management of residents with cognitive impairments to prevent similar incidents.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to accurately assess and address a resident's significant weight loss, which was observed in one of the five residents reviewed for weight loss. The resident, a male with multiple health conditions including muscle wasting, diabetes, and a chronic leg ulcer, experienced a notable weight loss of 6% in one month and 11% since admission. Despite being on a regular diet with double portions of protein, the resident continued to lose weight, dropping from 208.8 pounds to 182.2 pounds over a period of less than two months. The dietary note indicated that the weight loss might be partially related to the removal of a cast, although the resident reported never having a cast, and there was no documentation of a cast in his electronic health record. The dietitian, who is responsible for monitoring weight loss, did not physically assess the resident and relied on incorrect information about the resident's condition. The dietitian recommended increasing the resident's liquid protein intake, but the physician's orders did not reflect this change, indicating a lack of communication and implementation of necessary interventions. The facility's policy on unplanned weight loss was not followed, as the resident's significant weight loss was not adequately addressed, leading to continued weight loss without appropriate interventions being put in place.
Inadequate Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement effective fall interventions for a resident, R45, who was at high risk for falls due to severe cognitive impairment and a history of falls. R45, an elderly resident with vascular dementia, hypertension, and weakness, experienced multiple falls while attempting to go to the bathroom unassisted. Despite being identified as a high fall risk, the interventions in place were inadequate, as they relied on reminders and call lights, which were ineffective due to R45's dementia. R45's fall incidents were documented, showing a pattern of falls occurring when the resident attempted to self-transfer to the bathroom. The care plan interventions, such as not leaving the resident unattended in the bathroom and encouraging the use of call lights, were not sufficient to prevent these falls. The resident's daughter expressed disappointment, noting that R45 had fallen multiple times while trying to use the bathroom, resulting in injuries, including a forehead laceration and a hip fracture requiring surgical repair. The facility's investigation confirmed that all of R45's falls involved attempts to go to the bathroom unassisted. Staff interviews revealed that reminders for R45 to wait for assistance were ineffective due to the resident's dementia. The Director of Nursing acknowledged that more frequent checks and a toileting schedule would have been more appropriate interventions. The facility's fall policy emphasized an interdisciplinary approach to fall prevention, but the specific interventions for R45 were not resident-centered or effective in preventing falls.
Inadequate Pain Management Post-Hip Surgery
Penalty
Summary
The facility failed to manage a resident's pain effectively after the resident underwent hip surgery. The resident, who had a history of a fractured left hip, dementia, hypertension, and weakness, was readmitted to the facility following surgical repair of the hip fracture. On multiple occasions, the resident was observed to be in severe pain, moaning and crying out, particularly during transfers and while using the toilet. Despite the resident's evident distress, the nursing staff did not administer the correct pain medication as per the hospital discharge orders. Instead, the resident continued to receive an outdated pain medication regimen that was insufficient for the increased pain levels following surgery. The hospital discharge orders specified a new pain medication regimen of Norco 5/325 to be administered every four hours, but this was not reflected in the resident's medication administration records. The outdated order, which prescribed Norco four times a day, remained in place, leading to inadequate pain management. The Director of Nursing later confirmed that the hospital discharge orders had not been correctly implemented, resulting in the resident experiencing severe pain that was not appropriately addressed by the facility's staff.
Sanitation Breach in Dish Handling
Penalty
Summary
The facility failed to ensure that dishes were handled in a sanitary manner to prevent cross-contamination, potentially affecting all 89 residents. During an observation, a dietary aide was seen placing dirty dishes and cups onto a dishwasher rack and pushing it into the dishwasher. Without washing her hands, she then handled clean dishes, placing them onto a storage rack. This process was repeated, indicating a lack of adherence to proper hand hygiene protocols. The dietary manager confirmed that staff members operating the dishwasher are required to wash their hands after handling dirty dishes and before touching clean ones to prevent cross-contamination. The facility's Dish Machine Operation policy also mandates the use of clean, washed hands when handling clean racks. The failure to follow these procedures was observed and acknowledged by the dietary manager.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure proper assessment and treatment of pressure ulcers for several residents, leading to deficiencies in care. For instance, a resident with a stage 3 coccyx pressure ulcer did not receive the prescribed medicated cream during wound care, and there was a lack of documented wound assessments after admission. The Director of Nursing (DON), who also serves as the wound nurse, acknowledged that wounds should be assessed on admission and weekly, but this was not consistently done. Another resident with a stage 2 pressure ulcer on the buttock was found without a treatment dressing, and bloody drainage was noted on the incontinent pad. The Registered Nurse (RN) was unsure why the dressing was missing, suggesting it might have been removed during a bed bath. The DON confirmed that the resident should have had a treatment dressing in place, but this was not adhered to. Additionally, a resident with sacral pressure wounds had inconsistent documentation and treatment orders. The Pressure Ulcer Weekly Wound Evaluation report did not include all open areas, and there was a significant gap in documentation. The DON admitted to falling behind on wound assessments, which should occur weekly. Another resident's treatment orders were not updated for 13 days, resulting in the resident not receiving the prescribed treatment. The facility's pressure ulcer prevention policy emphasizes the need for timely identification and treatment, which was not followed in these cases.
Failure to Perform Daily Weights for CHF Resident
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of congestive heart failure (CHF) received daily weights as ordered. The resident, who has multiple diagnoses including acute on chronic combined systolic and diastolic heart failure, myocardial infarction, atrial fibrillation, chronic kidney disease, shortness of breath, hypertension, chronic obstructive pulmonary disease, and atherosclerotic heart disease, had a physician's order dated 2/28/24 for daily weights due to CHF. However, the Weights and Vitals summary indicated that between 7/13/24 and 10/22/24, the resident did not receive weights on numerous specified dates. The Director of Nursing confirmed that daily weights are crucial for CHF residents to monitor for weight gain or fluid overload and should be recorded in the electronic medical record. The facility's policy mandates that weights be recorded in the individual's medical record.
Failure to Provide Required Range of Motion Care
Penalty
Summary
The facility failed to provide appropriate care for a resident, identified as R27, to maintain or improve her range of motion (ROM) and mobility. R27, who has intact cognition, suffered a stroke resulting in impairment of her left upper and lower extremities. Despite her condition, the facility did not ensure that passive range of motion (PROM) exercises were performed on her left arm and leg, nor was a splint applied to her contracted left hand as required by her care plan. Observations over several days confirmed that R27 did not have a splint on her left hand and reported that she had not received the necessary exercises. Interviews with facility staff revealed a lack of communication and understanding of R27's needs. The Restorative Aide, V10, was unaware that R27 required PROM and assumed she preferred to perform exercises independently. Additionally, the Physical Therapy Assistant, V9, acknowledged that R27 could not move her left side due to flaccidity but noted that a splint had been tried in the past without success. The facility's Restorative Nursing Policy emphasizes the importance of maintaining optimal physical function, yet the care plan's directives for R27 were not followed, leading to the deficiency.
Failure to Provide Timely Psychiatric Services for Resident
Penalty
Summary
The facility failed to ensure timely psychiatric services for a resident experiencing increased depression. The resident, a male with a history of major depressive disorder, anxiety, and other medical conditions, was observed making self-harm threats and exhibiting behaviors such as placing a garbage bag over his head. On 9/9/24, a Nurse Practitioner noted the resident's increased depression and ordered an immediate psychiatric evaluation. However, the psychiatric consultation did not occur until 9/16/24, seven days later, due to a lack of communication and the unavailability of the psychiatric provider, who was on vacation. The Director of Nursing (DON) acknowledged that the referral was sent but was unaware that the order required same-day attention. The facility's policy mandates individualized interventions for changes in mental status, but the delay in psychiatric evaluation indicates a failure to adhere to this policy. The resident's care plan, which includes monitoring for suicidal ideations and arranging for psychiatric consultations, was not effectively implemented, contributing to the deficiency.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that a resident's medications were administered according to standards of practice. On the morning of 10/21/24, a resident was observed with eight pills in a medication cup on her bedside table while she was eating breakfast, with no nurse present. The resident stated that those were her morning pills. A registered nurse, V6, confirmed that she had already administered the resident's morning medications and was unaware of any medications left on the bedside table. V6 acknowledged that medications should never be left in a resident's room and that the nurse should ensure the resident takes the medications before leaving. Later, V6 re-entered the resident's room and found that the pills were gone. The resident stated she had taken the pills after finishing breakfast, which she claimed the nurse had left for her. The Director of Nursing, V2, confirmed that it is not the facility's practice to leave medications in a resident's room, as it prevents the nurse from ensuring the medication was taken. The nursing notes indicated that the nurse had observed the resident take her morning medications with the nurse present, and there was no cup of medication at the bedside after administration. The physician was updated on the probable ingestion of additional unknown medications.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to adhere to regulations regarding the administration of PRN psychotropic medications for a resident. Specifically, the facility did not limit the use of an as-needed antipsychotic medication, Haloperidol Lactate, to 14 days, nor did it include a stop date on the Physician's Order Sheet (POS). Additionally, the facility did not ensure that an as-needed antianxiety medication, Lorazepam, had a stop date documented on the POS. These omissions were identified during a review of the resident's medication orders, which showed that the orders for both medications lacked the required end dates. The Director of Nursing (DON) acknowledged that all psychotropic medications should be ordered for only 14 days unless extended by a physician, and that orders must include a stop date. The facility's policy on psychotropic medication use, dated September 2022, also stipulates that PRN psychotropic medications should be limited to 14 days unless a longer duration is justified by the attending physician. Despite these policies, the facility did not comply with the CMS requirement for a 14-day limit on PRN antipsychotic orders, nor did it ensure proper documentation and evaluation for extending the use of these medications.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Dixon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Square | 1.5 mi | ★★★★★ | 9 | 0 |
| Franklin Grove Living And Rehab | 8.6 mi | ★★★★★ | 15 | 0 |
| La Bella Of Sterling | 10.8 mi | ★★★★★ | 2 | 0 |
| Rock Falls Rehab & Hlth Care C | 10.9 mi | — | 0 | 0 |
| Polo Rehabilitation & Hcc | 11.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.