Not rated by CMS — ratings are suppressed for new or low-volume facilities.
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 Nursing & Rehab during CMS and state inspections, most recent first.
The facility did not have a qualified Infection Preventionist (IP) for its Infection Prevention and Control (IPC) program. The DON acknowledged the absence of a licensed IP and is working on hiring someone qualified. The administrator was unaware of the requirement for the IP to dedicate specific hours to infection prevention duties.
The facility failed to provide an ongoing activity program on weekends, affecting residents' mental and psychosocial well-being. The activity calendar showed limited options, with only movies and church services scheduled. Residents expressed dissatisfaction with the lack of engaging activities and the absence of activity staff on weekends. Interviews with staff confirmed the lack of staff-led activities, with the Activities Director and DON acknowledging the issue but citing a lack of available staff.
The facility failed to maintain the required RN coverage of eight consecutive hours per day, seven days a week, due to staffing shortages and scheduling issues. The DON, responsible for scheduling, was the only full-time RN, with one part-time RN, leading to coverage gaps on weekends. The administrator was unaware of the non-compliance due to a misunderstanding of shift timing and staffing challenges, despite efforts to recruit more staff.
The facility failed to implement policies for the Medication Regimen Review (MRR) process and did not communicate pharmacy recommendations to physicians for four residents. The MDS Coordinator did not receive or follow up on the MRR reports for September, leading to a lack of documentation and communication with physicians. Residents involved had various cognitive impairments and medical conditions, and their records lacked necessary documentation of pharmacist reports and physician responses.
Facility staff failed to follow proper hand hygiene and food storage practices. A Dietary Aide was observed handling soiled and clean wares without washing hands and improperly storing items in bulk food bins. The facility's guidelines lacked specific instructions on handwashing and food storage, contributing to these deficiencies.
Facility staff failed to follow policies for pneumococcal vaccinations, resulting in five residents not being assessed or vaccinated according to CDC guidelines. Despite signed consents, there was no documentation of the vaccine being offered, received, or refused. Interviews revealed a lack of awareness and documentation by the MDS Coordinator, DON, and administrator regarding the vaccination status of residents.
The facility failed to notify residents or their representatives of the bed hold policy during hospital transfers, as required by their guidelines. Medical records for four residents lacked documentation of such notifications. Interviews with staff, including an LPN, the DON, and the administrator, revealed a lack of awareness and execution of the policy, with some attributing the oversight to emergencies and the use of agency staff.
Facility staff failed to maintain a medication error rate below five percent, resulting in a 10.34% error rate due to improper insulin administration. A CMT did not prime Humalog Kwik Pens before administering insulin to three residents with Diabetes Mellitus, leading to potential dosing errors. The facility lacked a specific policy for insulin administration, contributing to the issue.
Facility staff failed to store medications safely, with insulin found in pooled water and controlled substances left unlocked. Insulin vials and pens on a medication cart were undated or expired, and staff lacked clarity on cleaning schedules and proper storage protocols.
The facility failed to ensure the activities program was directed by a qualified professional. The AD did not have the required certification, and the facility lacked a policy on AD qualifications. The AD was informed by the Administrator that certification was required after one year of employment. The DON was unaware of the AD's lack of certification and was not involved in the hiring process.
Facility staff failed to use a gait belt during a transfer, resulting in a resident being hospitalized with a shoulder injury. The resident, who required substantial assistance and was non-weight bearing, was lowered to the floor when their leg gave out, and staff heard a popping noise in the shoulder. Staff involved did not follow the facility's policy on gait belt use, and the incident was reported to the appropriate personnel.
Facility staff failed to document the administration of Milk of Magnesia for a resident who did not have a bowel movement for several days, despite a physician order. The facility's policy lacked guidance on documentation, and interviews revealed a lack of a system to audit daily reports. Staff were expected to follow physician orders and document bowel movements, but no medication was administered as required.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) to oversee its Infection Prevention and Control (IPC) program. The facility's policy requires an IP who is qualified through education, training, and experience, and who has completed the CDC Long Term Care Infection Preventionist module. However, during interviews, the Director of Nursing (DON) admitted that the facility currently lacks a licensed IP and is in the process of hiring someone qualified for the role. The DON also mentioned plans to complete the necessary modules to serve as a backup IP. Additionally, the administrator indicated that the DON and an agency employee are handling the IP role, but was unaware of the requirement for the IP to dedicate a specific number of hours to infection prevention duties.
Lack of Weekend Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing activity program designed to meet the residents' interests, mental, and psychosocial well-being on weekends for five out of 14 sampled residents. The facility's policy, dated March 2012, mandates an ongoing program of activities to meet these needs. However, the activity calendar for October and November 2024 showed only a movie on Saturdays and church on Sundays, with no other activities scheduled. Interviews with residents revealed dissatisfaction with the lack of weekend activities, with some describing the existing activities as childish and expressing a desire for more engaging options like Bible studies or social gatherings. Residents also noted the absence of activity staff on weekends, leading to a lack of structured activities. Interviews with facility staff, including CNAs, LPNs, the Activities Director, the DON, and the administrator, confirmed the absence of staff-led activities on weekends. The Activities Director mentioned setting out puzzles and coloring materials, but acknowledged no specific activities for residents with dementia or visual impairments. The DON and administrator were aware of the requirement for staff-led activities but cited a lack of available staff to conduct them. The administrator also noted that activities were intended to be self-directed on weekends, with occasional movies and church services, but was unaware of the need for staff-led activities during this time.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, as required. The facility's RN staff schedule from May to November 2024 showed multiple instances where there was no RN coverage for the required duration on weekends. The facility census was 30, and the absence of RN coverage was noted on specific dates across several months, indicating a pattern of non-compliance with the regulatory requirement. Interviews with facility staff revealed that the Director of Nursing (DON) was responsible for maintaining the schedule and was aware of the requirement for RN coverage. However, the DON was the only full-time RN, with one part-time RN available, which contributed to the coverage gaps. The facility administrator acknowledged the regulation but was unaware that the coverage was not being met due to a misunderstanding of shift timing and challenges in staffing. Efforts to recruit additional staff were mentioned, including using a new hiring platform and advertising through radio and online platforms.
Failure to Implement Medication Regimen Review Policies
Penalty
Summary
The facility failed to develop and implement policies and procedures to address appropriate timeframes for the Medication Regimen Review (MRR) process and failed to communicate pharmacy recommendations to the physician for four residents. The MDS Coordinator did not receive the MRR reports for September from the pharmacy and did not follow up with the Director of Nursing (DON) or the pharmacist, resulting in a lack of communication with the physician. The facility did not have a specific written policy to address the timeframes for the MRR process, although staff had been in-serviced on what to do. Resident #2, who was severely cognitively impaired and had multiple diagnoses including Traumatic Brain Injury and Schizophrenia, did not have documentation of the pharmacist's report or the physician's response to recommendations in their medical record. Similarly, Resident #4, who was moderately cognitively impaired with diagnoses such as anemia and Heart Failure, also lacked documentation of the pharmacist's report or physician's response. Resident #12, who was cognitively intact with conditions like High Blood Pressure and Diabetes Mellitus, had a blank Section N2001 and no documentation of the pharmacist's report or physician's response. Resident #19, who was severely cognitively impaired with diagnoses including Alzheimer's Disease and Stroke, also had a blank Section N2001 and lacked documentation of the pharmacist's report or physician's response. Interviews with facility staff revealed that the MDS Coordinator was responsible for communicating the MRR reports to the physician and documenting them in the electronic medical record (EMR). However, the MDS Coordinator did not receive the reports for September and did not follow up, resulting in the reports not being communicated to the physician. The DON and the administrator were not aware that the reports were not being addressed or uploaded to the residents' EMR. The facility's corporate Quality Assurance nurse confirmed the absence of a specific written policy for the MRR process timeframes.
Deficiencies in Hand Hygiene and Food Storage Practices
Penalty
Summary
The facility staff failed to adhere to proper hand hygiene practices, as observed during multiple instances involving a Dietary Aide (DA) identified as F. DA F was seen handling soiled kitchen wares with bare hands and subsequently handling clean wares without washing hands. This included activities such as precleaning soiled wares, handling clean silverware, and preparing drinks for residents. Additionally, DA F was observed opening a trash can with bare hands and then handling clean items without washing hands. The facility's handwashing guidelines, dated May 2015, did not specify when staff should wash their hands, contributing to the deficiency. The facility also failed to store food in a manner that prevents potential contamination. Observations revealed that bulk food storage bins contained inappropriate items such as a foam cup in a sugar bin and a metal scoop in a flour bin. These items were not supposed to be stored in the bins, as confirmed by staff interviews. The facility's policies lacked guidance on bulk food storage, which contributed to the improper storage practices observed. Interviews with staff and the Corporate Quality Assurance nurse confirmed the expectations for hand hygiene and food storage, which were not met in these instances.
Failure to Administer Pneumococcal Vaccines as per Policy
Penalty
Summary
The facility staff failed to adhere to their policies and procedures for the immunization of residents against pneumococcal disease, as recommended by the CDC. Specifically, five residents, all over the age of 65, were not assessed or vaccinated according to the guidelines. The facility's policy requires consultation with the resident's physician to determine the need for vaccinations and mandates that pneumococcal vaccinations be administered to adults aged 65 and older unless contraindicated. However, the medical records of these residents showed that although they had signed consents for the pneumococcal vaccine, there was no documentation indicating that they were offered, received, or refused the vaccine. Interviews with facility staff, including the MDS Coordinator, DON, and the administrator, revealed a lack of awareness and follow-through regarding the vaccination status of residents. The MDS Coordinator acknowledged responsibility for checking immunizations upon admission but admitted to not documenting refusals in the preventative health tab. The DON and the administrator both expressed expectations that vaccines should be administered within a week of admission if not previously received and that refusals should be documented. However, they were unaware that several residents had not received their pneumococcal vaccines, indicating a breakdown in communication and procedure adherence within the facility.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility staff failed to provide written notification of the bed hold policy to residents or their representatives at the time of transfer to a hospital for four residents. The facility's policy requires that residents and their representatives be informed of the bed hold guidelines upon admission, during hospital transfers, and at the time of non-covered therapeutic leave. However, the medical records for these residents did not contain documentation that such notifications were provided when they were discharged and subsequently readmitted. Interviews with facility staff revealed a lack of awareness and execution of the bed hold policy. An LPN admitted to not knowing the policy specifics, while the DON acknowledged that the charge nurse is responsible for ensuring the policy is followed but was unaware it was not being done. The administrator also noted that the nurse responsible for sending a resident out should handle the bed hold process but suggested that emergencies might have led to oversight. The facility's use of agency staff was mentioned, with an assumption that they had been educated on the policy.
Failure to Prime Insulin Pens Leads to Medication Errors
Penalty
Summary
The facility staff failed to maintain a medication error rate of less than five percent, resulting in a 10.34% error rate. This was observed during the administration of insulin using Humalog Kwik Pens to three residents. The errors occurred because the Certified Medication Technician (CMT) did not prime the insulin pens before administering the insulin, as required by the manufacturer's instructions. The lack of priming could lead to incorrect dosing due to air bubbles in the pen. The facility did not have a specific policy for insulin administration, which contributed to the errors. Resident #4, #12, and #26, all diagnosed with Diabetes Mellitus, were affected by these errors. Each resident received insulin injections as part of their treatment plan. The CMT administered insulin without priming the pen, contrary to the manufacturer's guidelines, which state that priming is necessary to ensure the correct dose is delivered. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), confirmed that priming should occur before each administration to avoid medication errors.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility staff failed to store medications safely and effectively, as observed in the medication storage room and on a medication cart. An observation revealed an unopened box of insulin medications with an illegible label saturated in a pool of water inside the medication room refrigerator. Interviews with the Director of Nursing (DON) and Certified Medication Technicians (CMTs) indicated a lack of clarity regarding the cleaning schedule for the medication refrigerators, which are supposed to be cleaned at the end of each month and as needed. The DON acknowledged that water should not be pooled inside the refrigerators. Additionally, the medication room was found unlocked, with an unlocked refrigerator containing controlled substances such as Lorazepam and an opened bottle of Whisky. The DON and other staff members confirmed that controlled substances should be stored behind double locks to prevent unauthorized access. However, the refrigerator was left open, and the staff did not provide a clear explanation for this oversight. Furthermore, the 200/400 hall medication cart contained several insulin vials and pens that were either undated, past expiration, or had illegible open dates. Interviews with CMTs and an LPN revealed that insulin should be labeled with the open date and is considered expired 28 days after opening. The staff responsible for administering insulin are expected to check expiration dates and discard expired medications. However, there was no system in place to double-check and ensure expired medications were removed from the medication carts.
Unqualified Activities Director
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional. The facility's policies did not include a policy regarding the qualifications for the Activity Director (AD) position. During an interview, the AD admitted to not having an activities director certification and stated that the Administrator informed them they needed to work at the facility for one year before obtaining certification. The Director of Nursing (DON) was unaware that the current AD was not certified and acknowledged that there were trainings available for certification but was not involved in the hiring process. The Administrator mentioned being told by the Director of Operations that the AD needed to work for one year before getting certified.
Failure to Use Gait Belt Results in Resident Injury
Penalty
Summary
Facility staff failed to use a gait belt to transfer a resident from a bedside commode to a chair, resulting in the resident being sent to the hospital with a significant injury. The resident was assessed as cognitively intact and required substantial to maximal assistance from staff with transfers, being non-weight bearing. During the transfer, the resident's leg gave out, and staff lowered the resident to the floor, hearing a popping noise in the resident's left shoulder. The facility's policy on gait belt use was not followed, as staff did not use a gait belt during the transfer. CNA B and CNA C were involved in the transfer and did not utilize a gait belt, despite the resident's known need for assistance. CNA B mentioned that the resident had refused the use of a gait belt in the past, but was unaware of the proper protocol to follow in such situations. Interviews with staff, including the LPN, MDS Coordinator, Administrator, and DON, confirmed that the resident required two-person assistance for transfers, which should have included the use of a gait belt or mechanical lift. The staff involved in the incident did not use a gait belt and instead placed their hands under the resident's arms, leading to the injury. The incident was reported to the appropriate personnel, and the resident was assessed and transferred to the hospital.
Removal Plan
- Facility staff investigated the cause of the resident's injury.
- In-serviced staff on how to perform a safe transfer of a resident with a gait belt.
- Staff corrected the deficient practice.
Failure to Document Medication Administration for Resident
Penalty
Summary
Facility staff failed to document the administration of medication for a resident, leading to a deficiency in meeting professional standards of quality. The facility's policy on physician orders lacked specific guidance on documenting medication administration. A resident, assessed as cognitively intact, had a physician order for Milk of Magnesia to be administered if they did not have a bowel movement in three days. However, the Medication Administration Record (MAR) showed no administration of the medication from September 20 to September 27, despite the resident not having a bowel movement during this period. Interviews with facility staff, including an LPN, CNA, MDS Coordinator, Administrator, and DON, revealed that staff were expected to follow physician orders and document bowel movements every shift. The nighttime charge nurse was responsible for printing a daily bowel movement report, which the day charge nurse would review. However, there was no documentation of medication administration after the resident did not have a bowel movement for over three days, and no system was in place to audit the daily reports. The deficiency was identified as a failure to follow physician orders and ensure proper documentation and administration of medication.
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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) |
|---|---|---|---|---|
| Life Care Center Of Waynesville | 14.7 mi | ★★★★★ | 2 | 0 |
| Maries Manor | 15 mi | ★★★★★ | 9 | 0 |
| Phelps Health | 16.9 mi | ★★★★★ | 0 | 0 |
| Cedar Pointe | 17 mi | ★★★★★ | 0 | 0 |
| Silverstone Place | 17 mi | ★★★★★ | 1 | 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.