Below 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 Dyer Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with end stage renal disease, heart failure, diabetes, and bilateral lower extremity impairment, who was cognitively intact and dependent on dialysis, did not receive fully documented dialysis monitoring as ordered and care planned. Although the care plan and physician orders required pre- and post-dialysis vital signs and assessment of the dialysis access site for redness, swelling, pain, or drainage, the MARs for two months lacked documentation of access site assessments, and several post-dialysis vital signs and related progress notes were missing. Facility policy required observation and documentation of dialysis access site findings, and during interview, a nurse consultant acknowledged the missing post-dialysis vitals and documentation.
Surveyors found that the facility failed to provide required ADL assistance, including timely incontinence care and at least twice-weekly bathing, for three dependent residents. One resident with chronic kidney disease, diabetes, and a history of UTIs was observed with a saturated brief and waited over 30 minutes for incontinence care after activating the call light, and records showed multiple missed scheduled baths despite a care plan requiring regular bathing and bed baths. Another resident, cognitively intact and always incontinent, had a care plan for hygiene assistance and was noted as resistive to care, yet bathing records showed very few baths over several months, with many scheduled bath days left blank or marked non-applicable and no documentation of refusals. A third resident with diabetes and schizophrenia, dependent for bathing and toileting, reported only being bathed when she asked, and her bathing records also showed numerous missed scheduled baths. These practices were inconsistent with facility policies requiring staff to maintain personal hygiene and provide routine incontinence care for residents unable to perform ADLs.
A resident with dementia and diabetes did not consistently receive care according to physician orders and professional standards. Ordered blood glucose checks and sliding-scale insulin doses were missed and not documented on multiple occasions, with no blood sugar results recorded elsewhere in the record. The same resident, who was also ordered olanzapine three times daily for psychosis, repeatedly refused the morning dose over an extended period, yet there was no documentation of physician notification, no evidence that the care plan intervention to crush medications was used, and no recorded reasons for the refusals. The DON later reported that the nurse indicated the resident was agitated in the mornings, and no additional interventions were attempted.
A resident with chronic kidney disease, diabetes mellitus, a history of UTIs, and a multi-drug resistant organism UTI, who was incontinent and dependent on staff for care, reported ongoing burning with urination. Nursing staff notified the NP, who ordered a UA with C&S, but the test was never completed, and there was no documentation of results in the record. The DON later confirmed that the ordered UA with C&S had not been carried out.
A facility failed to maintain an accurate controlled-drug system when a resident’s scheduled Norco could not be located and narcotic count documentation was missing. Staff gave conflicting accounts about how many medication cards were in the narcotic box, and the resident’s MAR showed missed doses with incomplete documentation. The resident had an active order for hydrocodone-acetaminophen for pain, and the facility had no narcotic count policy in place at the time.
Failure to Monitor Blood Pressure per Physician’s Orders: A resident with hypertensive heart disease and CKD was receiving multiple BP-related medications, including spironolactone, midodrine, metoprolol, and bumetanide. The physician ordered vital signs every shift, but the MAR showed they were not checked every shift, and the DON stated the order had not been transcribed to the MAR.
Failure to Use Required PPE for EBP and Contact Isolation: Two CNAs did not use the required gown and gloves correctly during resident care. One CNA began incontinence care for a resident on Contact Isolation and EBP before donning a gown, and another CNA provided incontinence care to a resident on EBP while wearing gloves but no gown. Both residents had orders for gown and gloves during high-contact care, and one CNA stated she was unsure of the EBP policy.
A resident with significant neurological and physical impairments developed new right lower extremity edema and pain, prompting a Doppler ultrasound that revealed a partial clot. The abnormal results were not promptly communicated to the ordering practitioner, resulting in a delay of several days before anticoagulant therapy was initiated.
A resident dependent on staff for ADLs and with significant physical and cognitive impairments was repeatedly observed with a soiled, raised shirt that exposed his body and incontinence brief, as well as food stains on his clothing and body. Staff were aware of the situation but did not address the resident's dignity needs throughout the day.
A dependent resident with significant cognitive and physical impairments did not receive timely incontinence care, resulting in prolonged exposure to soiled clothing and incontinence brief. Staff observed the resident with visible soiling and food debris on his clothing and body, and confirmed that incontinence care had not been provided for several hours despite awareness of the need. The care plan and facility policy required routine assistance, which was not followed in this instance.
The facility failed to provide adequate assistance with ADLs, including meal assistance, oral care, and personal hygiene, for several residents. Observations showed delays in meal assistance and neglect in providing regular showers and nail care. Residents with cognitive impairments and those dependent on staff were particularly affected, with staff interviews confirming these deficiencies.
The facility failed to document and administer insulin properly for two residents, neglected to monitor and treat skin conditions and edema for two residents, and inadequately addressed a change in condition for another resident, leading to hospitalization. The Director of Nursing acknowledged the documentation lapses, and the Assistant Director of Nursing was unaware of a resident's deteriorating condition until the following day.
The facility failed to supervise residents in the memory care unit during meals, as observed on multiple occasions. Residents were left unsupervised while eating, with one resident consuming another's milk and another eating a jelly packet without staff present. The Director of Nursing confirmed that residents should be supervised during meals, indicating a lapse in oversight.
The facility failed to implement proper infection control practices, including inadequate disinfection of multi-use equipment, improper hand hygiene, and incorrect handling of medications. Staff were observed not following protocols for using personal protective equipment and managing soiled linens. Additionally, personal care equipment was improperly stored, violating the facility's infection prevention and control program.
A resident with cognitive impairment and dependency on staff for dressing was repeatedly observed wearing a hospital gown in bed during the day, compromising her dignity. Despite her condition, there was no care plan addressing her attire preferences, as confirmed by the DON.
The facility failed to assess and authorize three residents for self-administration of medications and oxygen. A resident used an Albuterol inhaler without a care plan or physician's order, another had unsupervised potassium medication left by an LPN, and a third used an oxygen concentrator independently without assessment. The facility did not follow its policies requiring evaluations for self-administration.
A facility failed to complete a PASARR level 2 when a new mental health diagnosis was added for a resident. The resident's record included diagnoses such as metabolic encephalopathy, dementia, and unspecified psychosis. A PASARR level I indicated no further screening was needed unless a serious mental illness was present. However, after the diagnosis of unspecified psychosis was added, no level 2 was performed. The Social Services Director acknowledged the oversight and indicated plans to redo the level 1 and arrange for a level 2 assessment.
A facility failed to create an individualized care plan for a resident with bilateral below-the-knee amputations. The resident, who was cognitively intact and required maximum assistance with ADLs, had a care plan that included inappropriate foot care interventions. The DON acknowledged the need to update the care plan to reflect the resident's current condition, given their medical history of ESRD, congestive heart failure, diabetes, and stroke.
The facility failed to involve two residents in decisions about their care, specifically regarding new medications and lab results. One resident was not informed about changes in medication, while another did not receive lab results directly, as they were communicated to a family member with POA. Both residents were cognitively intact, and the lack of communication was confirmed by facility staff.
A facility failed to apply a physician-ordered splint for a resident with limited range of motion due to a stroke and hemiplegia. The resident was observed multiple times without the required anti-contracture device, despite a care plan and physician's order for a daily resting hand splint. Staff interviews revealed confusion over responsibility for the splint application, and records showed no documentation of the splint being applied for several months.
Two residents with a history of weight loss were not adequately assisted with meals or had their nutritional supplement consumption documented. One resident was left unattended with her meal and consumed another's milk, while another played with her food without staff intervention. Both residents had significant weight loss and required assistance with eating, as confirmed by the DON.
The facility failed to follow proper procedures for gastrostomy tube care for two residents. An RN administered medication to a resident without checking for residuals and used a syringe plunger instead of gravity. Another resident's peg tube site care was not documented, and water was pushed through the tube with a syringe plunger. The facility's policies were not followed, leading to deficiencies in care.
The facility failed to administer oxygen at the correct flow rate for three residents. A resident with COPD was observed using oxygen at four liters per minute instead of the prescribed two liters. Another resident received oxygen at 1.5 and one liter per minute, contrary to the order of two liters. A third resident used oxygen at three liters per minute, despite an order for two liters as needed. The DON confirmed the discrepancies.
The facility exceeded the acceptable medication error rate with errors involving three residents. A resident received incorrect insulin and antibiotic dilution, another was given a discontinued medication, and a third received an incorrect dosage of Lexapro. The errors were confirmed by the DON.
The facility failed to ensure a controlled substance was double locked in one of the medication rooms. An unlocked refrigerator contained an unlocked hospice box with Morphine Sulfate Roxanol 20 mg, a Schedule II controlled substance. The ADON confirmed the box should have been locked, as per facility policy requiring double lock storage for Schedule II medications.
A resident did not receive routine dental services due to a failure in the facility's process. The resident, who was cognitively intact and had a diagnosis of dysphasia, expressed a desire for dental treatment. Despite having a signed consent form for dental services, no appointments were documented. The facility switched dental providers, and the resident was accidentally skipped because they did not sign a new consent form.
The facility failed to administer medications as ordered for two residents. A resident did not receive Vitamin D due to a pharmacy delay, and another resident's senna was documented as given despite being unavailable. The facility lacked a re-ordering policy.
A resident with significant cognitive impairment and a left femoral fracture experienced inadequate pain management due to the facility's failure to monitor and assess pain, evaluate medication effectiveness, and attempt non-pharmacological interventions as required by physician's orders. Despite frequent complaints of knee pain, the facility did not consistently document pain assessments or manage the resident's pain effectively, leading to the need for surgical repair.
A facility failed to implement a behavior plan for a resident with dementia who exhibited aggressive behaviors. During a combative episode, an LPN intervened without being asked and allegedly became rough, resulting in the resident's ears being reddened. The behavior care plan, which included interventions to deescalate agitation, was not effectively followed, leading to the escalation of the resident's aggressive behavior.
A facility failed to accurately document the administration of Norco for a cognitively impaired resident with a history of falls. Discrepancies were found between the Controlled Drug Form and the MAR, with missing or inconsistent records of medication administration and pain assessments. The DON confirmed the need for accurate documentation on both records.
A facility failed to provide effective pressure ulcer prevention and treatment for a dependent resident, resulting in a facility-acquired sacral pressure injury that deteriorated and required hospitalization for septic shock and surgical debridement. The facility's staff did not consistently assist with repositioning, and there were gaps in communication and documentation regarding the resident's skin condition and necessary interventions.
The facility failed to provide adequate supervision during a mechanical lift transfer for a resident with right-side paralysis, resulting in a fracture. Additionally, the facility did not ensure fall prevention interventions, such as keeping call lights within reach, for another resident with a history of falls.
A facility failed to timely document a resident's change in condition, with late entries made 9 days after the event. The resident, with a complex medical history, experienced abnormal vital signs and loss of consciousness, necessitating an emergency room transfer. The delay in documentation was attributed to a busy shift change and miscommunication between nursing staff.
Failure to Document Post-Dialysis Vitals and Access Site Assessments
Penalty
Summary
The facility failed to provide complete and documented dialysis-related monitoring for a resident receiving renal dialysis. The resident had diagnoses including heart failure, end stage renal disease, diabetes, bilateral lower extremity impairment, and was dependent on dialysis. An MDS assessment indicated the resident was cognitively intact for daily decision making. The care plan, initiated in June and revised in February, identified the need for dialysis related to renal failure and included interventions to assess the dialysis access site for redness, swelling, pain, or drainage, and to encourage attendance at scheduled dialysis appointments. A physician’s order dated December 19 directed staff to record vital signs pre- and post-dialysis, and another order dated March 2 directed staff to assess the dialysis access site for redness, swelling, pain, and drainage. Record review showed that there was no physician’s order to assess the dialysis access site until March 2, despite the care plan intervention to do so. The MARs for January and February lacked documentation of dialysis access site assessments. The January MAR showed post-dialysis vital signs coded with a “9” (indicating to see progress notes), but there were no corresponding progress notes for multiple dialysis dates in January. Additionally, the February MAR lacked any documented post-dialysis vital signs on one dialysis date. The facility’s Dialysis Monitoring and Communication Policy required observation of the dialysis access site for increased redness, swelling, bleeding, pain, and drainage, and documentation of abnormal findings in the medical record. During interview, the Nurse Consultant acknowledged the absence of post-dialysis vital signs on the identified February date and understood the concern regarding missing January post-dialysis progress notes and lack of access site assessments.
Failure to Provide Required Bathing and Timely Incontinence Care for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide required ADL assistance, including timely incontinence care and bathing at least twice weekly, for residents dependent on staff. One resident was observed lying in bed with an uncovered, visibly saturated incontinence brief and reported waiting to be cleaned. Her call light was not activated until prompted, and although an RN responded and stated the CNA would be notified, incontinence care was not provided until over 30 minutes later. The resident, who had chronic kidney disease, a history of UTIs, diabetes mellitus, and was always incontinent of bowel and bladder per MDS, reported that she sometimes went one to two weeks without a bath and had previously gone six weeks without being bathed. Review of her care plan and shower schedule showed she was to receive bathing twice weekly with bed baths on non-shower days, but bathing records documented multiple missed scheduled baths over several months. A second resident’s closed record showed she was cognitively intact, always incontinent of bowel and bladder, and dependent on staff for toileting, bathing, and hygiene. Her care plan required assistance with ADLs and hygiene, and a later care plan noted she was resistive to care, with interventions to allow her to make decisions and be educated on outcomes of non-compliance. The shower schedule indicated twice-weekly bathing, but bathing input forms showed she received only three of eight scheduled baths in one month, a single bed bath in the following month, and no showers or baths in the subsequent month before discharge. Several scheduled bathing dates were left blank or marked non-applicable, and there was no documentation that she refused or resisted bathing. The DON confirmed she could not locate documentation of refusals and acknowledged a lack of twice-weekly bathing. A third resident, who had diabetes mellitus and schizophrenia and was dependent for toileting and bathing per MDS, stated she only received bathing when she asked staff. Her care plan required assistance with ADLs and hygiene, and the bathing schedule called for twice-weekly evening baths. Bathing input forms showed she received only four of eight scheduled baths in one month and five of nine in the next, with multiple dates marked non-applicable. The DON was unable to provide additional information or documentation explaining the missed baths. Facility policies on ADLs and bowel and bladder incontinence required that residents unable to perform ADLs receive necessary services to maintain personal hygiene and that staff routinely provide incontinence care, including brief changes, pericare, and clothing and linen changes, which were not consistently carried out for these residents.
Failure to Administer and Document Insulin and Antipsychotic Medications as Ordered
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident with dementia and diabetes mellitus when ordered blood glucose testing and insulin administration were not consistently completed or documented. The resident had a care plan for diabetes indicating medications would be administered as ordered and an MDS showing she received insulin and an antipsychotic. A physician’s order required Humalog insulin to be given twice daily at specific times based on sliding-scale dosing after blood glucose testing. The MAR for one month showed that blood glucose testing was not completed at several ordered times, and there was no documentation of blood sugar results or whether insulin was or was not administered. No corresponding glucose results were found in progress notes or blood glucose listings. The facility also failed to follow physician orders and care plan interventions related to an antipsychotic medication, olanzapine, ordered three times daily for psychosis. The MAR documented repeated refusals of the 6:00 a.m. dose on numerous days over two consecutive months. There was no documentation that the physician had been notified of these missed doses, no evidence that the care plan intervention to crush medications as needed had been implemented, and no documentation of the reasons for the refusals. During interview, the DON reported that the nurse assigned on the refusal days stated the resident was agitated in the morning, and no other interventions had been attempted, despite a facility policy stating medications were to be administered in a safe, accurate, and effective manner.
Failure to Complete Ordered UA with C&S for Resident with Recurrent UTI
Penalty
Summary
The deficiency involves the facility’s failure to complete a urinalysis (UA) with culture and sensitivity (C&S) as ordered for a resident with a history of urinary tract infections. The resident, who had diagnoses including chronic kidney disease, history of UTIs, and diabetes mellitus, reported having burning with urination for a while and indicated that different medications had been tried without resolving the infection. A quarterly MDS assessment documented that the resident was cognitively intact, dependent on staff for bathing and toileting, required maximum assistance with bed mobility, and was always incontinent of bowel and bladder. The care plan, last reviewed in mid-December, indicated the resident required enhanced barrier precautions due to a multi-drug resistant organism UTI. On a late-December date, a nurse’s progress note documented the resident’s complaint of burning with urination, and the NP was notified, resulting in an order for a UA with C&S. The NP’s order, dated the following day, specified that a UA with C&S was to be collected. However, there was no documentation in the medical record that the laboratory test was ever completed. During an interview, the DON confirmed that the ordered UA with C&S had not been completed, demonstrating that the facility did not ensure the ordered laboratory test was obtained and results communicated as required.
Missing narcotic medication and incomplete controlled-drug accounting
Penalty
Summary
The facility failed to establish and maintain a system that accounted for, periodically reconciled, and ensured the disposition of controlled drugs after a scheduled narcotic medication for one resident could not be located. The resident had an active order for hydrocodone-acetaminophen 7.5-325 mg, 1 tablet by mouth three times daily for pain, and the August 2025 MAR showed doses that were not administered on multiple occasions, with entries marked as "9 - other/see progress notes" and one dose left blank. No narcotic count sheets were available for the resident. A Facility Reported Incident documented that staff discovered the resident’s scheduled analgesic medication was missing and initiated a search of medication carts and medication rooms, but the medication could not be found. Interviews with nursing staff produced conflicting accounts about how many Norco medication cards were in the narcotic box and whether the resident’s medication was present. One LPN reported that when she last worked there were four cards in the narcotic box, while another reported there were only two cards and later changed her statement when asked about the resident’s Norco pills. Another nurse recalled receiving additional Norco cards from pharmacy and placing them in the narcotic box. The record also showed that two hydrocodone-acetaminophen medication cards had been delivered, each containing 21 pills, but the resident’s cards were not in the narcotic box and the narcotic count sheet was missing. Facility staff interviewed the nurses who had cared for the resident during the relevant shifts, and both were sent for drug testing. The nurse consultant stated that the missing medication was identified after the shift-to-shift review, and that the facility had no policies related to narcotic counts at the time of the incident.
Failure to Monitor Blood Pressure per Physician’s Orders
Penalty
Summary
Facility failed to ensure Resident B’s blood pressure was monitored per Physician’s Orders while the resident was receiving multiple medications affecting blood pressure. Resident B’s record showed diagnoses including hypertensive heart disease and chronic kidney disease. Physician’s Orders included spironolactone 50 mg daily, midodrine 5 mg three times a day with a noted major side effect of systolic supine hypertension, an order for vital signs every shift, metoprolol tartrate 25 mg twice a day, and bumetanide 1 mg twice a day. The Medication Administration Record for 11/2025 indicated that vital signs had not been checked every shift as ordered. During interview, the DON stated the order had not been transcribed to the MAR.
Failure to Use Required PPE for EBP and Contact Isolation
Penalty
Summary
The facility failed to ensure correct PPE was used by staff when providing care to residents on Enhanced Barrier Precautions and Contact Isolation. During an observation, CNA 1 responded to Resident E’s call light for an incontinence brief change. A sign on the door indicated Contact Isolation and EBP precautions were required. CNA 1 completed hand hygiene, applied gloves, and prepared supplies, but did not don a gown until after being stopped and then noticing the sign at the entry door. Resident E’s record showed diagnoses including diabetes mellitus, UTI, and Klebsiella Pneumoniae, with an admission MDS indicating maximum assistance for toileting and bathing and occasional bowel and bladder incontinence. The care plan and physician’s order required EBP for Klebsiella Pneumoniae and specified gown and gloves for high-contact resident care activities. During another observation, CNA 2 was in Resident L’s room after completing incontinence care and was wearing gloves but no gown, despite a door sign indicating both residents required EBP. CNA 2 stated she was unsure of the facility’s EBP policy and then read the sign on the door. Resident L’s record showed diagnoses including spinal stenosis and UTI, with an annual MDS indicating maximum assistance for toileting and bed mobility, dependence on staff for bathing, moderate assistance for hygiene, and frequent bowel and bladder incontinence. The physician’s order required EBP related to MDROs in the urine and specified gown and gloves for high-contact resident care activities.
Delay in Reporting Doppler Results Leads to Delayed Treatment
Penalty
Summary
A resident with a history of stroke, aphasia, hemiparesis, dysphagia, and weakness experienced new onset edema and pain in the right lower extremity. In response, a physician ordered a Doppler ultrasound to assess for possible vascular issues. The Doppler was completed and interpreted, revealing partial clotting in the superficial femoral vein. However, there was no documentation that the abnormal results were communicated to the physician or nurse practitioner upon receipt. From the time the Doppler results were available, there was no follow-up or notification to the ordering practitioner for several days. The lack of timely communication resulted in a delay in treatment, as the resident did not receive an order for anticoagulant therapy until several days after the results were available. The Director of Nursing confirmed that the results were reported by the interpreting company but could not determine when or if the results were relayed to the physician, acknowledging the delay in treatment.
Failure to Maintain Resident Dignity Related to Soiled and Exposed Clothing
Penalty
Summary
A resident with a history of stroke, left side hemiplegia, Parkinson's disease, major depressive disorder, hypertension, and anxiety disorder, who was dependent on staff for activities of daily living (ADLs) including toileting, bathing, dressing, and required substantial to maximum assistance with eating, was observed multiple times throughout the day with dignity concerns. The resident was seen sitting in a wheelchair with his shirt raised, exposing his abdomen, back, and sides, as well as his incontinent brief. There was a wet red stain and scrambled eggs on his clothing and body, which remained unaddressed for several hours. A white towel was later placed over the front of his shirt, but the shirt remained raised and soiled, and the resident continued to be exposed in public areas. Staff interviews confirmed awareness of the resident's soiled and exposed state, with a CNA acknowledging the presence of dried stains and food on the resident's clothing and body. The resident's care plan indicated the need for assistance with personal hygiene, dressing, and eating, but these needs were not met in a manner that maintained the resident's dignity. The Director of Nursing also acknowledged that the resident's shirt should have been pulled down and changed.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a dependent resident, who required assistance with activities of daily living (ADLs) including toileting, bathing, and dressing, did not receive timely incontinence care. During a morning observation, the resident was found sitting in a wheelchair with his shirt raised, exposing his abdomen, incontinence brief, and back. There was a wet red stain on the shirt, and scrambled eggs were present on his shorts and lower abdomen. Later that day, when the resident was returned to his room for incontinence care, staff discovered the brief was heavily soiled with urine and bowel movement, and dried scrambled eggs were still present near the pubic area. The CNA confirmed that although the resident had been showered and changed before breakfast, he had not been changed again until the afternoon, despite being aware of the soiling. The resident's medical record indicated multiple diagnoses, including stroke with left side hemiplegia, Parkinson's disease, and cognitive impairment, necessitating substantial to maximum assistance with ADLs. The care plan required staff to check and change the resident as needed for incontinence. Documentation showed inconsistent recording of incontinence care, and the facility's policy required routine assistance with incontinence care, including brief and clothing changes. The DON acknowledged that incontinence care should have been provided more promptly.
Deficiencies in ADL Assistance and Personal Hygiene
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs) were adequately completed for dependent residents, affecting 12 out of 14 residents reviewed. Observations revealed that residents were not assisted with meals in a timely manner, with some residents left without assistance for extended periods. For instance, Resident E, who was cognitively impaired and required setup assistance with eating, was observed not receiving timely help during meal times. Similarly, Resident M, who needed substantial assistance with eating, was left without her meal tray set up and was not assisted promptly. Additionally, the facility did not provide adequate oral care, shaving, and nail care for several residents. Resident K, who was dependent on staff for oral hygiene, was observed with dry, cracked lips over multiple days, indicating a lack of daily oral care. Resident O had long fingernails digging into his skin, and Resident B had long, dirty fingernails and was not assisted with shaving, despite expressing a preference for being clean-shaven. These observations highlight a pattern of neglect in personal hygiene and grooming needs. The facility also failed to provide regular showers or bed baths as scheduled. Multiple residents, including Residents G, H, and P, reported not receiving showers twice a week as per their care plans. Documentation in the electronic records often lacked evidence of showers being given or resident refusals being recorded, indicating a systemic issue in maintaining personal hygiene schedules. Interviews with staff confirmed these deficiencies, with the Director of Nursing acknowledging the lapses in care.
Deficiencies in Insulin Administration and Resident Monitoring
Penalty
Summary
The facility failed to ensure proper documentation and administration of insulin for two residents with diabetes. Resident S had multiple instances where blood sugar levels and insulin administration were not documented in the Medication Administration Record (MAR) across several months. Similarly, Resident R's MAR showed numerous occasions where insulin was not signed out as administered, despite having specific physician orders for insulin administration based on a sliding scale. The Director of Nursing acknowledged that the insulin and blood sugar results should have been documented. The facility also failed to provide appropriate treatment and monitoring for non-pressure related skin conditions and edema. Resident T, who was at risk due to antiplatelet therapy, had multiple discolored areas and a skin tear that were not properly assessed or treated. The facility did not have orders to monitor these conditions, and the Director of Nursing confirmed that such areas should have been monitored every shift. Additionally, Resident F had a swollen hand and excoriated skin patches that were not assessed or treated, and the hospice aide was unaware of any treatment for these conditions. Furthermore, the facility did not adequately address a change in condition for Resident Q, who exhibited signs of respiratory distress and dehydration. Despite observations of a congested cough and gurgling, there was no documented assessment of lung sounds or timely follow-up on the resident's condition. The resident was eventually sent to the hospital with influenza A, healthcare-associated bacterial pneumonia, and acute kidney injury. The Assistant Director of Nursing was unaware of the resident's condition until the following day, highlighting a lack of communication and timely intervention.
Lack of Supervision During Meals in Memory Care Unit
Penalty
Summary
The facility failed to ensure adequate supervision for residents in the memory care unit during meal times, as observed on multiple occasions. On one occasion, four residents were left unsupervised in the memory care unit lounge while eating their lunch. Resident R was served a meal that included whole pork, which was not cut into smaller pieces, and Resident 81 was served a pureed meal. Resident R drank Resident 81's lactose-free milk without any staff present to assist or supervise. Similarly, Residents 6 and L were eating their meals without staff supervision. A CNA entered the room later but did not supervise these residents, indicating a lack of oversight during meal times. On another occasion, Resident 81 was observed eating a jelly packet unsupervised in the dining room. Later, when lunch trays were delivered, the Assistant Director of Nursing began distributing them, but once the CNA left to deliver trays to other residents, there was no staff present to supervise the residents in the dining room. This lack of supervision was confirmed during an interview with the Director of Nursing, who stated that residents were supposed to be supervised while eating. These observations highlight a consistent failure to provide necessary supervision during meals, potentially compromising resident safety.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices, as observed in several instances involving staff and residents. In one case, CNAs did not disinfect a Hoyer lift after use and failed to perform hand hygiene after glove removal. The lift was used in multiple resident rooms without being disinfected until much later. Additionally, a CNA was observed handling soiled linens improperly, dragging them through the hallway and wearing gloves outside the resident's room, which is against the facility's infection control policy. In another instance, an RN was observed preparing medications for residents by dispensing them into her bare hand, which is contrary to the facility's policy that requires avoiding direct contact with medications unless gloves are worn. Furthermore, the RN did not perform hand hygiene before or after administering medications. Another RN failed to sanitize hands before and after checking a resident's blood pressure and blood sugar, and did not disinfect the glucometer after use, which was meant for multiple residents. Environmental observations revealed improper storage of personal care equipment, such as wash basins and bed pans, which were found uncontained and in inappropriate locations like the floor or on the back of toilets. These practices were not in line with the facility's infection prevention and control program, which mandates proper containment and storage of such items to prevent cross-contamination and maintain hygiene standards.
Resident Dignity Compromised by Inappropriate Attire
Penalty
Summary
The facility failed to maintain the dignity of a resident by allowing her to wear a hospital gown while in bed during the day. This was observed multiple times over several days, with the resident consistently found in her room wearing a hospital gown. The resident, who has diagnoses including dementia without behavior disturbance, dysphagia, and gastrostomy status, was noted to be cognitively impaired and dependent on staff for dressing. Despite these observations, there was no care plan in place addressing the resident's preference or need to wear a gown during the day, as confirmed by a review of the resident's care plan and an interview with the Director of Nursing.
Failure to Assess and Authorize Self-Administration of Medications and Oxygen
Penalty
Summary
The facility failed to ensure that residents were properly assessed and had physician's orders to self-administer medications and oxygen therapy. Three residents were involved in this deficiency. Resident 91 was observed with an Albuterol inhaler on her over bed table, which she brought from home and used daily without a care plan or physician's order for self-administration. The resident was cognitively intact, but there was no assessment completed to determine her ability to self-administer the medication. The facility's policy required an interdisciplinary team to evaluate the resident's capacity to self-administer medications, which was not done in this case. Resident 105 was found with a cup containing potassium medication on her over bed table, which was left unsupervised by an LPN who was called away for an emergency. The resident had no care plan or assessment indicating she could consume medication without supervision. Additionally, Resident 30 was using an oxygen concentrator independently without an assessment or order for self-administration. The resident was cognitively intact and had a physician's order for oxygen as needed, but the facility failed to assess his ability to use the oxygen correctly. The facility's policies required staff to remain with residents while administering medication and to assess residents' ability to self-administer oxygen, which were not followed in these instances.
Failure to Complete PASARR Level 2 for New Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure a PASARR (preadmission screening and resident review) was completed when a new mental health diagnosis was added for a resident. The resident's record, reviewed on February 7, 2025, included diagnoses such as metabolic encephalopathy, dementia, and unspecified psychosis not due to a substance or known physiological condition. A PASARR level I, dated January 10, 2025, indicated no further screening was needed unless the resident had a serious mental illness or intellectual development disability. However, the diagnosis of unspecified psychosis was added to the resident's record on January 13, 2025, and no PASARR level 2 was performed. During an interview on February 4, 2025, the Social Services Director acknowledged that a level 2 PASARR was not conducted and mentioned plans to redo the level 1. She was uncertain if the psychosis diagnosis was present since a prior hospitalization. A subsequent PASARR level I, completed on February 5, 2025, indicated the need for a face-to-face level 2 assessment. The Social Services Director later confirmed arrangements were being made for the level 2 assessment.
Inadequate Individualized Care Plan for Amputee Resident
Penalty
Summary
The facility failed to develop an individualized care plan for a resident with bilateral below-the-knee amputations. During a random observation, it was noted that the resident, who was cognitively intact and required maximum assistance with activities of daily living (ADLs), had a care plan that included foot inspection and podiatry services, which were inappropriate given the resident's amputations. The resident's medical history included end-stage renal disease (ESRD), congestive heart failure, diabetes, and stroke. The Director of Nursing (DON) acknowledged that the care plan should have been updated to reflect the resident's current condition, specifically removing the foot care interventions that were no longer applicable.
Failure to Involve Residents in Care Decisions
Penalty
Summary
The facility failed to ensure that residents were involved in decisions about their care, specifically regarding the communication of new medications and lab results. Resident 4, who was cognitively intact, reported not being informed about new medications prescribed by her doctor. The resident's records showed changes in medication orders, including the discontinuation of Xarelto and the initiation of Aspirin and Plavix, as well as the start of Bactrim and other medications for urinary tract infections. However, there was no documentation indicating that Resident 4 was informed of these changes, although her daughter was notified. Additionally, there was a missing care plan conference for Resident 4, as confirmed by the Social Service Director. Resident 30, also cognitively intact, expressed concerns about not receiving his lab results directly, as they were communicated to his sister, who was the power of attorney. The resident had undergone lab testing on multiple occasions, but there was no documentation that he was informed of the results. The Assistant Director of Nursing acknowledged that the family member was updated due to their POA status but stated that the resident would be informed of his results. These deficiencies highlight a lack of communication and involvement of residents in their care planning and decision-making processes.
Failure to Apply Physician-Ordered Splint for Resident with Limited ROM
Penalty
Summary
The facility failed to ensure that a resident with a limited range of motion had a physician-ordered splint in place. The resident, who had a history of stroke and hemiplegia affecting the left side, was observed multiple times without the required anti-contracture device in his left hand. The resident's left hand was noted to be flaccid and closed, and he was unable to open it without assistance. Despite a care plan indicating the need for a splint due to a contracture in the left hand, and a physician's order specifying the application of a resting hand splint daily for a minimum of four hours, the splint was not documented as being applied in the treatment and medication administration records for several months. Interviews with staff revealed a lack of clarity regarding responsibility for applying the splint. A CNA indicated that the restorative team was responsible for the splint, and the Director of Nursing had no additional information to provide. There was no documentation in the care plan that the resident refused the splint, indicating a lapse in the facility's adherence to the prescribed care plan and physician's orders, leading to the deficiency.
Failure to Assist Residents with Meals and Document Nutritional Intake
Penalty
Summary
The facility failed to ensure adequate assistance with meals and documentation of nutritional supplement consumption for two residents with a history of weight loss. Resident R was observed on multiple occasions sitting with her meal in front of her without any staff assistance. On one occasion, she drank a carton of milk belonging to another resident, and on another, she consumed a health shake without encouragement to eat her meal. Her care plan indicated she required supervision or assistance with eating due to cognitive impairments and a significant weight loss of over 10% in six months. Similarly, Resident 81 was observed playing with her food and using her fingers to eat without staff intervention. She was seen pouring her beverage over her food and attempting to place her plate on the floor, mistaking it for a dog's dish. Despite her care plan indicating a need for supervision or assistance with eating, staff were not present to assist or encourage her to eat properly. Her weight records showed a significant weight loss of 11.2% in three months, necessitating staff assistance with meals. Interviews with the Director of Nursing confirmed that both residents required more assistance with eating, and there was a lack of documentation regarding the consumption of health shakes for Resident R. The facility's failure to provide necessary assistance and documentation contributed to the residents' nutritional deficiencies.
Deficiencies in Gastrostomy Tube Care for Two Residents
Penalty
Summary
The facility failed to ensure proper procedures were followed for residents with gastrostomy tubes, leading to deficiencies in care for two residents. For Resident 72, an RN administered medication through a gastrostomy tube without checking for residuals beforehand and used a syringe plunger to push water and medication through the tube instead of allowing them to instill by gravity. This was contrary to the facility's policy, which requires checking the tube's placement and residuals before administering medication and using gravity for flushing and medication administration. For Resident K, the facility did not document proper care of the peg tube site, and an RN used a syringe plunger to push water through the tube to check for patency, rather than using gravity. The resident, who had multiple diagnoses including cerebral palsy and dysphagia, was observed not connected to enteral feeding as per physician orders. Additionally, there were no documented orders for daily cleaning of the peg tube site, and the care plan did not include necessary instructions for site care, which is required to decrease the risk of infection.
Oxygen Flow Rate Discrepancies for Residents
Penalty
Summary
The facility failed to ensure that oxygen was administered at the correct flow rate for three residents who required oxygen therapy. Resident T, diagnosed with chronic respiratory failure and COPD, was observed using oxygen at a flow rate of four liters per minute, despite a physician's order for two liters per minute. This discrepancy was noted over several days, and the Director of Nursing confirmed that the oxygen concentrator should have been set to the prescribed flow rate. Similarly, Resident G, who has COPD, was observed receiving oxygen at a flow rate of 1.5 liters per minute and later at one liter per minute, contrary to the physician's order of two liters per minute. Resident 30, with diagnoses including COPD and sleep apnea, was using oxygen at three liters per minute, although the physician's order specified two liters per minute as needed. The LPN acknowledged the incorrect setting and intended to adjust it, but the Director of Nursing later confirmed the flow rate remained incorrect.
Medication Error Rate Exceeds 5% Due to Multiple Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by four errors observed during 34 opportunities, resulting in an error rate of 11.7%. For Resident 72, a registered nurse (RN) administered 8 units of Lispro insulin instead of the prescribed 10 units for a blood sugar level between 351 and 400. Additionally, the RN improperly diluted Entrapenem with 10 cc's of normal saline, contrary to the physician's order to dilute it only with 3.2 mls of Lidocaine. The Director of Nursing confirmed these errors during an interview. Resident 9 received a 5 mg tablet of Buspirone, which had been discontinued two days prior, indicating a failure to remove the medication from the cart. For Resident 114, a licensed practical nurse (LPN) dispensed only one 5 mg tablet of Lexapro instead of the prescribed three tablets. The Director of Nursing acknowledged that the resident should have received the correct dosage. These errors highlight the facility's failure to adhere to physician orders and ensure proper medication administration.
Controlled Substance Not Double Locked
Penalty
Summary
The facility failed to ensure that a controlled substance was double locked at all times in one of the two medication rooms observed. During an observation of the West Unit Medication Room, it was found that an unlocked refrigerator contained an unlocked white hospice box with Morphine Sulfate Roxanol 20 mg, a Schedule II controlled substance. The Assistant Director of Nursing (ADON) confirmed that the hospice box should have been locked due to the presence of narcotics. The facility's policy on receiving controlled substances requires medications listed in Schedules II, III, IV, and V to be stored under double lock, which was not adhered to in this instance.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services to a resident, identified as Resident J, who was reviewed for dental services. During an interview, Resident J expressed a desire to see a dentist for routine treatment. The resident's record, reviewed on February 5, 2025, showed a diagnosis of dysphasia and indicated that the resident was cognitively intact according to the Quarterly Minimum Data Set (MDS) assessment dated December 9, 2024. A signed dental consent form from March 28, 2024, confirmed the resident's wish to receive dental services offered by the facility. However, there was no documentation of any dental appointments being completed for the resident. The Social Service Director provided documentation indicating that the facility switched to a different dental company in July 2024, and during an interview, it was revealed that the resident did not sign a consent form for the new dental company, resulting in the resident being accidentally skipped for dental services.
Medication Administration Deficiencies for Two Residents
Penalty
Summary
The facility failed to ensure that two residents received necessary care and services related to medication administration as ordered by their physicians. For Resident F, during a random observation, it was noted that Vitamin D was missing from the medication cart, despite being ordered from the pharmacy days earlier. The resident's records showed that Vitamin D2 was to be administered daily, but there was a gap in administration on one day in September. The pharmacy audit revealed a delay in the delivery of the medication, and the Director of Nursing confirmed that the medication was on back order. For Resident G, during a medication administration observation, it was found that the morning dose of senna was not available in the medication cart. The medication had last been ordered in July and delivered in early August. The records indicated that the senna was administered daily, but the Nurse Consultant acknowledged that the medication would have been depleted by early September, suggesting that the medication was documented as given when it was not available. The facility's medication administration policy required medications to be administered according to physician's orders, but a policy for re-ordering medications was not provided.
Inadequate Pain Management for Resident with Fracture
Penalty
Summary
The facility failed to provide adequate pain management for a resident with a comminuted, displaced left femoral fracture. The resident, who had significant cognitive impairment and was dependent on assistance for toileting and transfers, was noted to have pain in the left knee, with swelling observed. Despite receiving scheduled and PRN pain medication, the facility did not consistently monitor and assess the resident's pain or evaluate the effectiveness of the medication. Non-pharmacological interventions were not attempted prior to administering pain medication, as required by the physician's orders. The resident's pain was not adequately documented, with missing pain assessments and ineffective pain management noted in the records. The resident frequently complained of knee pain, and staff were aware of her discomfort, yet there was a lack of appropriate response and documentation. The facility's failure to adhere to the care plan and physician's orders resulted in inadequate pain management for the resident, who ultimately required surgical repair for the fracture.
Failure to Implement Behavior Plan for Resident with Dementia
Penalty
Summary
The facility failed to implement a behavior plan of care for a resident with dementia who exhibited challenging and aggressive behaviors. The incident involved a resident diagnosed with Alzheimer's dementia, depression, and peripheral vascular disease, residing in a locked memory care unit. During a combative episode while being changed by two CNAs, a nurse intervened without being asked for assistance. The nurse allegedly became rough with the resident, resulting in the resident's ears being reddened. Witness statements from the CNAs indicated that the nurse tapped the resident's ears in an attempt to calm him, but this did not deescalate the situation. The nurse was terminated for failing to deescalate the situation. The resident's behavior care plan, revised prior to the incident, included interventions such as providing physical and verbal cues to alleviate anxiety and giving positive feedback. Staff were instructed to intervene before agitation escalated and to walk away calmly if the response was aggressive, reapproaching later. However, during the incident, these interventions were not effectively implemented, leading to the escalation of the resident's aggressive behavior. The facility's failure to adhere to the behavior care plan contributed to the deficiency identified in the report.
Inaccurate Documentation of Pain Medication Administration
Penalty
Summary
The facility failed to ensure thorough and accurate documentation of medical records related to the administration of pain medication for a resident with significant cognitive impairment and a history of repeated falls. The resident, who was dependent on assistance for toileting and transfers, was prescribed Norco for pain management. However, discrepancies were found between the Controlled Drug Receipt/Record/Disposition Form and the electronic Medication Administration Record (MAR) regarding the administration of Norco. The records showed inconsistencies in the dates and times the medication was administered, and there were instances where the MAR did not reflect the administration of the medication as recorded on the Controlled Drug Form. Additionally, the documentation of the resident's pain levels was incomplete, with some shifts lacking pain assessments and others showing discrepancies in pain evaluation. Nurses' notes indicated the resident experienced pain and received medication, but follow-up notes often lacked details about the effectiveness of the medication or the specific location of the pain. The Director of Nursing confirmed that prn Norco should be documented on both the Controlled Drug Form and the MAR for each administration, highlighting a failure in maintaining accurate and complete medical records.
Failure to Prevent and Treat Pressure Ulcer Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide effective services to a dependent resident at risk of developing pressure injuries, resulting in the resident developing a facility-acquired pressure injury on the sacrum. This injury deteriorated and exhibited signs of infection, ultimately leading to the resident experiencing a significant change in condition that required hospitalization for wound-related septic shock and surgical debridement. The resident's medical history included stroke, subarachnoid hemorrhage, respiratory failure, bipolar disorder, aphasia, vascular implants and grafts, spina bifida with shunts, and a history of breast cancer. Upon admission, the resident was incontinent, bedfast, and required maximum assistance with mobility, with no pressure ulcers present at that time. However, the facility did not implement effective interventions for pressure relief as indicated in the care plan and physician's orders dated 3/4/24. The facility's records indicated that staff failed to consistently remind or assist the resident with repositioning every two hours, as required. Documentation showed that staff did not assist with repositioning on 26 of 39 shifts between 3/5/24 and 3/17/24. Additionally, a discolored area was found on the resident's skin on 3/6/24, but it was not thoroughly assessed or documented, and the nurse on duty did not recall being notified. The facility's wound nurse did not assess the area until 3/15/24, by which time the injury had deteriorated to an unstageable pressure ulcer with significant necrotic tissue. The facility's documentation and care plans did not include sufficient interventions to provide complete pressure relief to the sacral area. The resident's condition continued to decline, and on 3/18/24, the resident was transferred to the emergency room with symptoms of septic shock. The hospital diagnosed the resident with a sacral wound infection and septic shock, and surgical debridement of the wound was performed. Interviews with facility staff revealed gaps in communication and documentation regarding the resident's skin condition and the implementation of appropriate interventions. The facility's policies for skin condition assessment and pressure ulcer prevention were not adequately followed, leading to the resident's significant decline in health and subsequent hospitalization.
Removal Plan
- The facility determined a deficiency in their wound prevention, assessment, and treatment program and immediately implemented a plan of improvement.
- Interventions were initiated for Resident C.
- All nurses were educated on skin assessments at the time of admission and any newly identified skin concerns.
- Nurses were educated on the policy if a new skin concern was found, a Risk Management Form was to be initiated, the Physician and family were to be notified, a treatment was to be obtained and initiated, and the DON and Wound Nurse was to be notified.
- Braden scales were to be completed and accurate with appropriate interventions, orders and care plans to be initiated for anyone with a low Braden score.
- The Clinical team were to audit and follow through with the treatments and plan of care.
- CNAs were educated to ensure the nurses were notified of all new skin concerns found during care, interventions to be implemented and where to find those interventions.
- For any concerns, the DON, Wound Nurse, and Administrator may be notified.
- All residents have had updated Braden Scales and those with changes had interventions initiated for prevention.
- Nursing staff and CNAs from different shifts were interviewed and all were knowledgeable of the policies and procedures they were educated on.
- The Administrator indicated staff who had not been educated would receive the education prior to working.
- Audits had been completed and were still ongoing to ensure Braden assessments, care plans, and interventions were in place.
- All information would be reviewed and submitted to the facility's Quality Assurance Program.
Inadequate Supervision and Fall Prevention
Penalty
Summary
The facility failed to ensure adequate supervision for Resident B during a sit-to-stand mechanical lift transfer. Resident B, who required two staff members for assistance due to a stroke with right-side paralysis and obesity, was transferred by only one CNA. This improper transfer resulted in Resident B sliding out of the sling, causing her right arm to get caught and leading to a fracture of the right humeral neck. The incident was witnessed, and the resident was found lying on the floor with a hematoma on the back of her head. Despite recommendations from therapy staff to use a full mechanical lift (Hoyer), the resident refused, preferring the sit-to-stand lift, which ultimately led to the fall and injury. Additionally, the facility failed to ensure that fall prevention interventions were in place for Resident F. During observations, Resident F was found lying in bed with the call light out of reach on multiple occasions. The resident, who had a history of falls and required assistance with bed mobility and transfers, was unsure how to call for staff assistance. Despite a fall occurring on a previous date, there were no updates or new interventions added to the care plan to address the risk of falls. The facility's policies on mechanical lift transfers and fall prevention were not adequately followed. The mechanical lifting device policy required two caregivers for residents needing two-person assistance, which was not adhered to in Resident B's case. Similarly, the fall prevention policy mandated that call lights be within residents' reach at all times, which was not ensured for Resident F. These failures contributed to the incidents and injuries sustained by the residents.
Failure to Timely Document Change in Resident's Condition
Penalty
Summary
The facility failed to ensure a Resident's record was completed in a timely manner, specifically related to a change in condition assessment that was not charted at the time of the change. Late entries were made 9 days after the event for one of the ten residents reviewed for medical records. Resident C, who had a history of stroke, subarachnoid hemorrhage, respiratory failure, bipolar disorder, aphasia, vascular implants and grafts, spina-bifida with shunts, and breast cancer, experienced a significant change in condition on 3/18/24. The resident had abnormal vital signs and a loss of consciousness, necessitating a transfer to the emergency room. However, the documentation of this change was not completed until 3/27/24, well after the event occurred. During an interview, the LPN responsible for the documentation indicated that the delay was due to a busy shift change and the assumption that the evening shift nurse would chart the change of condition. This lapse in timely documentation was identified during a record review and interview, highlighting the facility's failure to maintain accurate and timely medical records in accordance with accepted professional standards. This deficiency was related to a specific complaint investigation (IN00430826).
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,272 citations issued within 25 miles in the last 12 months — including the 12 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dyer
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ignite Medical Resort Dyer Llc | 1.2 mi | ★★★★★ | 4 | 0 |
| Great Lakes Healthcare Center | 2.2 mi | ★★★★★ | 34 | 0 |
| Rehabilitation Center At Hartsfield Village | 2.6 mi | ★★★★★ | 11 | 0 |
| Munster Med-inn | 3.3 mi | — | 44 | 2 |
| Aliya Of Glenwood | 4.3 mi | ★★★★★ | 20 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Dyer Nursing And Rehabilitation Center.
100% money-back within 48 hours.
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.