Dixon Rehab & HCC

In the surveyor’s words

From the most serious findings on record at Dixon Rehab & HCC, in the surveyor’s own words.

• Actual harm, isolatedF686Jan 15, 2025

  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. 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. […]

• Actual harm, isolatedF686Nov 23, 2024

  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. The findings include: 1. […]

• Actual harm, isolatedF686Oct 23, 2024

  Based on observation, interview and record review the facility failed to ensure pressure ulcers were assessed, prescribed treatment orders were transcribed and provided, and treatment dressings were in place for residents with pressure ulcers. These failures apply to 4 of 5 (R179, R6, R66, R55) residents reviewed for pressure ulcers in the sample of 18. The findings include: 1. R179's face sheet shows she is a [AGE] year old female admitted to the facility on [DATE], from another facility. Her diagnoses include COPD, unspecified dementia without behavioral disturbance, type 2 diabetes, multiple sclerosis, gastrostomy status, unspecified cerebral infarction. On 10/21/24 at 9:24 AM, V7 (Licensed Practical Nurse/LPN) provided wound care to R179. […]

• Actual harm, isolatedF689Oct 23, 2024

  Based on observation, interview and record review the facility failed to ensure effective fall interventions were in place for resident's safety who is a high risk for falls and has a history of falls. This failure resulted in R45 falling out of bed and sustaining a left hip fracture needing surgical repair for 1 of 18 residents (R45) reviewed for safety in the sample of 18. The findings include: R45's Physician Order Sheet show R45 is [AGE] year old with diagnoses of vascular dementia, hypertension, weakness and left hip fracture R45's facility assessment dated [DATE] show R45 is severely cognitively impaired (BIMS of 1) R45's fall risk assessment dated [DATE] show R45 as a high risk for falls. On 10/21/24 at 9AM, R45 was in bed moaning I am sore. […]

• Actual harm, isolatedF692Oct 23, 2024

  Based on observation, interview and record review the facility failed to accurately assess a residents weight loss and ensure nutritional interventions were implemented for a resident with significant weight loss. This failure resulted in R66's significant weight loss. This applies to 1 of 5 residents (R66) reviewed for weight loss in the sample of 18. The findings include: R66's face sheet shows he is a [AGE] year old male admitted to the facility on [DATE] with diagnoses including muscle wasting, encounter for orthopedic aftercare following surgical amputation, acquired absence of left leg below the knee, type 2 diabetes, peripheral vascular disease, and a non-pressure chronic leg ulcer of right lower extremity. […]