Dixon Healthcare Center

In the surveyor’s words

From the most serious findings on record at Dixon Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jul 29, 2025

  Based on closed medical record review, review of hospital records, review of Medscape medical reference information, policy review, and interviews, the facility failed to protect Resident #64's right to be free from neglect. This resulted in Immediate Jeopardy and Actual Harm with subsequent death beginning on [DATE] when the facility failed to provide timely and appropriate goods and services to meet Resident #64's total care and medical needs and failed to ensure the resident received timely and necessary care and treatment to prevent serious illness and death. On [DATE] Resident #64 returned from the hospital with orders for Lasix (diuretic) 20 milligrams (mg) daily and basic metabolic profile (BMP) laboratory test to be completed on [DATE]. […]

• Immediate jeopardy, isolatedF684Jun 2, 2025

  Based on closed medical record review, facility policy and procedure review, and interview, the facility failed to provide timely, necessary and adequate care and services following an acute change in condition involving Resident #63. The facility failed to ensure changes in the residents' medical condition were comprehensively assessed, the resident change in condition, including abnormal vital signs, was communicated to the medical health provider, and individualized interventions were implemented for Resident #63 when the resident was identified by therapy staff to have a decline in health including tachycardia, hypoxemia, and excessive daytime sleepiness and lethargy. […]

• Immediate jeopardy, isolatedF600Mar 20, 2025

  Based on closed medical record review, review of hospital records, review of an emergency medical service (EMS) report and EMS staff statements, review of facility Self Reported Incidents, review of a facility investigation, review of the facility dialysis policy and procedure, review of the facility Abuse/Neglect policy and procedure and interviews with staff, the coroner, and resident, the facility failed to prevent an incident of neglect when Resident #72 did not receive timely and necessary care to prevent major blood loss from his hemodialysis fistula site. This resulted in Immediate Jeopardy and Actual Harm with subsequent death beginning on [DATE], when Resident #72, who had intact cognition and required hemodialysis, was seen by dialysis staff, picking at his fistula site. […]

• Immediate jeopardy, isolatedF600Aug 22, 2024

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, emergency room record review, review of a facility Self-Reported Incident (SRI), review of the facility investigation, review of the news broadcast at https://wtov9.com/news, employee code of conduct review, staff interviews, resident interview and review of facility policy, the facility failed to prevent staff to resident sexual abuse. This resulted in Immediate Jeopardy and the potential for actual physical and psychosocial harm on 08/08/24 at approximately 11:10 A.M. […]

• Actual harm, isolatedF684Apr 21, 2026

  Based on open and closed medical record review, facility policy review, and interviews, the facility failed to timely identify a change in resident condition and notify the medical provider to prevent a delay in treatment/timely medical intervention. The facility also failed to ensure bowel protocols were implemented for residents on hospice services. Actual harm occurred on 03/11/26 when Resident #54, who had bilateral nephrostomy tubes and history of kidney disease, experienced a decline in functional status, decreased urine output from the nephrostomy tubes, and decreased food and fluid intake without evidence of necessary and timely medical intervention or notification to the resident's medical provider. […]