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 Ignite Medical Resort Dyer Llc during CMS and state inspections, most recent first.
Medications Not Administered or Monitored as Ordered: A resident with HTN, CKD, HF, osteomyelitis, and urine retention had multiple ordered meds missed or delayed, including carvedilol, midodrine, vancomycin, enoxaparin, metoprolol succinate ER, and empagliflozin. The MAR and notes showed no documented reason for several omitted doses and no evidence the MD was notified. Midodrine was also given without required BP checks, and the DON and Nurse Consultant acknowledged the meds were not administered or monitored as ordered.
Missing Completion and Documentation of Ordered Lab Tests: The facility failed to ensure ordered lab services were completed for two residents. One resident with multiple chronic conditions had several ordered blood and stool tests with no documentation that they were completed or that the MD was notified, and another resident with UTI, DM, Parkinson's disease, and dementia had an ordered urinalysis with no result in the record and no documentation that the MD was informed. The DON acknowledged the missing documentation and stated the lab orders were sent electronically to the contracted lab.
Incomplete bladder scan documentation: The facility failed to record the amount of urine found during ordered bladder scans for two residents. One resident had urine retention and multiple chronic conditions, and the other had UTI, DM, Parkinson's disease, and dementia. Although the MAR showed the scans were completed, there was no documentation of scan results in the MAR, Nurses' Progress Notes, or Bladder Scan Evaluation forms, and the DON confirmed the missing documentation.
Failure to use required PPE during EBP care: two CNAs provided high-contact care to two residents on EBP while wearing gloves but not gowns. One resident had a feeding tube, and the other had a midline IV catheter and an open toe area; both residents had EBP signs on their doors and care plans/orders requiring gowns and gloves during high-contact care.
A deficiency was cited due to the presence of accident hazards in an area and insufficient staff supervision to prevent accidents. Surveyors observed that the environment was not maintained to ensure resident safety, and staff oversight was inadequate.
A crash cart was found with an empty oxygen tank during a review, and staff were unsure of the frequency for checking oxygen levels, despite facility policy requiring nightly checks. The DON confirmed that oxygen should be checked daily.
A resident with multiple lower limb wounds and complex medical history did not have updated wound care orders implemented after receiving new instructions from wound care and podiatry appointments. Although the new orders were documented in progress notes, they were not transcribed into the physician order summary or carried out in the treatment administration record, resulting in the resident not receiving the prescribed wound care regimen.
Nursing staff failed to consistently verify G-tube placement, check and document residuals, and flush feeding tubes as required by physician orders and facility policy for three residents receiving enteral nutrition. In multiple observed and documented instances, tube placement and residuals were not checked prior to bolus feedings, post-feeding flushes were omitted, and required documentation was missing from the MAR.
Surveyors found multiple instances of unlabeled and improperly stored food items in the kitchen, including unlabeled powders, liquids, and open bags of food in storage areas, as well as uncovered and unlabeled prepared foods. The Kitchen Manager confirmed that facility policies requiring labeling, dating, and covering of food items were not followed, potentially affecting all residents receiving meals from the kitchen.
Staff failed to assess and monitor bruises for two residents on anticoagulant therapy, did not adequately monitor or document constipation for a resident on opioid medication, and did not properly assess or document edema or the use of a compression glove for another resident. Additionally, medications were administered outside of prescribed blood pressure parameters for a resident with cardiovascular conditions.
A resident with COPD, chronic respiratory failure, and dementia was left to complete nebulizer treatments independently without a physician's order or assessment confirming safe self-administration. The resident had moderate cognitive impairment and required assistance with daily living, yet staff did not remain present during treatments, contrary to facility policy requiring evaluation and physician authorization.
The facility did not notify physicians when three residents experienced significant changes, including elevated blood sugars, withheld blood pressure medication, and missed insulin doses. Documentation and interviews confirmed that required notifications to the physician or NP were not made when residents' conditions changed or medications were not administered as ordered.
A resident with multiple diagnoses, including Alzheimer's disease, was admitted to hospice care with a terminal prognosis, but the MDS assessment failed to reflect the resident's hospice status and terminal condition. MDS nurses later confirmed the resident was receiving hospice care and had a terminal prognosis.
A resident with hypertension, end stage renal disease, and diabetes was observed using oxygen and had right hand edema with a compression glove at bedside. The care plan addressed only general edema prevention and did not include specific interventions for the right hand edema, compression glove use, or oxygen therapy.
A CNA placed a tube feeding pump on hold for a resident with a gastrostomy and severe cognitive impairment before performing incontinence care, despite state guidelines requiring a nurse to handle the pump. The CNA's action was observed, and a nurse resumed the feeding after care.
A resident with multiple chronic conditions and moderate cognitive impairment was not assisted by facility staff in obtaining an eye doctor appointment, despite requests from the resident and his daughter. There was no documentation of vision care in the resident's record, and a staff member informed the family that arranging such care was not part of the facility's responsibilities.
A resident received a G-tube flush that was pushed through the tube using a syringe plunger by an LPN, instead of being administered by gravity as required by facility policy. The LPN later confirmed the correct procedure should have been to allow the flush to flow by gravity.
A resident with multiple chronic conditions was observed receiving oxygen therapy without a current physician order or care plan in place, despite facility policy requiring such documentation. The DON confirmed that no current orders for oxygen were found in the resident's chart.
A medication error rate above 5% was observed when an LPN administered insulin to a resident with type 2 diabetes, failing to prime the insulin pen and giving 20 units instead of the ordered 18 units, in violation of facility policy.
An LPN prepared medications for a resident and left a pill card of multivitamin, a pill card of ferrous sulfate, and a medication cup with the resident's morning medications on top of the medication cart. The LPN then left the cart unattended and out of sight while going to the Nurse's Station, leaving the medications unsecured until returning several minutes later. The LPN acknowledged that medications should not have been left unattended.
A resident with multiple medical conditions, including COPD and dementia, reported ill-fitting dentures and difficulty chewing, but had not received a dental evaluation since admission. When the resident's daughter requested help from a social worker to arrange dental care, she was told the facility could not assist. No documentation of dental care was found in the resident's record.
A resident with diabetes and heart failure had incomplete documentation on the MAR for several doses of Droxidopa, with staff confirming the medication was given but not recorded. Additionally, an order for Midodrine lacked required blood pressure parameters, and the DON was unable to locate these in the record.
A resident with heart failure did not receive their prescribed medication, Vericiguat, due to unavailability. The facility failed to notify the physician of this delay in a timely manner, as required by policy. The Director of Nursing confirmed the oversight, noting that the physician should have been informed after 48 hours. The issue was eventually resolved without the family's involvement.
A facility failed to ensure correct PPE usage by a CNA when providing care to a resident under Enhanced Barrier Precautions (EBP). The CNA assisted the resident, who had a feeding tube, without wearing a gown, despite the facility's policy requiring it for high-contact care. The incident was observed during a complaint investigation.
A facility failed to provide necessary treatment for a resident with a pressure ulcer. Observations revealed the resident's heels were not offloaded as required, and a low air loss mattress was not used as intended. Additionally, a skin barrier cream was not applied during incontinent care, contrary to the care plan. The resident had a DTI on the right heel, and the care plan included specific interventions that were not followed, leading to inadequate care.
Two LPNs failed to use the correct PPE while providing care to a resident under Enhanced Barrier Precautions (EBP) due to a Deep Tissue Injury (DTI) on the right heel. Despite a sign indicating the need for PPE and the availability of PPE in the room, the LPNs only wore gloves and did not don gowns as required by the facility's EBP policy.
A facility failed to notify a resident's responsible party of significant changes in the resident's medical status, including IV site placement, medication changes, and treatment for high potassium levels. The resident, who was cognitively impaired, experienced changes such as the insertion of a PICC line and adjustments in medication without the responsible party being informed, as required by facility policy.
A facility failed to assist a resident with personal hygiene needs, specifically in trimming long fingernails. The resident, who was cognitively intact and required supervision with personal hygiene, expressed a lack of access to nail clippers and indicated that staff had not offered assistance. Despite the resident's request for help, their fingernails remained untrimmed until a later observation confirmed they had been cut. The resident's medical history included a fracture of the left femur, osteoarthritis, and lack of coordination.
A facility failed to assess and monitor bruising in a resident on anticoagulant therapy. The resident, with a history of multiple health conditions, was observed with discolorations on their forearms and hands. Despite orders for regular skin checks and anticoagulant use, there was no care plan for the bruising, and skin assessments lacked documentation of new concerns.
The facility failed to properly maintain and monitor IV catheters for two residents. One resident did not receive documented saline flushes before and after antibiotic administration due to an error in the MAR listing. Another resident experienced discomfort from an IV site that was not monitored for infection, and there were no orders for saline flushes to maintain patency. The facility's policy on IV site monitoring was not followed, leading to inadequate care.
The facility failed to document wound care treatments for a resident with a surgical wound and pressure ulcer, as the Wound Nurse did not sign off on the TAR despite completing the treatments. Additionally, a resident with dementia experienced a fall, but the required fall risk evaluation was not completed immediately, leading to incomplete documentation. The CNO had to facilitate the evaluation over the phone after the incident.
A facility failed to document and communicate necessary information for a resident with metabolic encephalopathy being transferred to the ER. The resident's discharge status was not recorded, and there was no documentation of a change of condition or transfer in the Nurses' Progress Notes. The DON confirmed that a family member called 911 for the transfer, but there was no transfer sheet completed, and it was unclear if the hospital ER received the resident's information.
The facility failed to accurately complete MDS assessments for two residents, leading to discrepancies in recorded information about falls, medications, and behaviors. One resident's MDS inaccurately indicated no falls or antipsychotic medication use, despite documented falls and behaviors. Another resident's MDS incorrectly reported no falls, although a fall was documented. These inaccuracies were identified during a complaint review.
The facility failed to create and implement individualized care plans for two residents, resulting in deficiencies. A resident with a knee immobilizer developed a pressure sore due to improper management, and there was no care plan to prevent this. Another resident with dementia had multiple behavioral episodes documented without a care plan to address these behaviors. The absence of care plans was confirmed by the DON and Social Service Director.
A resident with diabetes and an abdominal wall abscess did not receive necessary care as prescribed. Antibiotics were not administered as ordered, and blood glucose levels were not monitored or reported to the physician when elevated. The DON confirmed these deficiencies during interviews.
A resident with severe cognitive impairment and high fall risk was found on the floor, but the facility failed to conduct a thorough investigation or determine the root cause of the fall. The care plan required identifying and addressing potential fall causes, but this was not done. The facility's fall prevention policy lacked a post-fall protocol, and the only intervention was placing a fall mat by the bedside.
A resident with dementia exhibited ongoing behavioral issues without proper input from the IDT and Social Services. The facility failed to develop a care plan or document interventions for behaviors such as restlessness, exit-seeking, and aggression. Despite physician's orders for non-pharmacological interventions before administering PRN medications, these were often not documented or attempted, leading to inadequate management of the resident's condition.
The facility failed to ensure correct PPE use by LPNs during wound care for a resident with pressure sores. No sign indicated the need for Enhanced Barrier Precautions (EBP), and EBP was not implemented, contrary to facility policy. This oversight potentially affected 13 residents requiring wound treatments.
The facility did not ensure the Nurse Staffing Information was current and accurate, as it was outdated and included Assisted Living staff instead of only Long Term Care staff. The Director of Nursing left the information for the Weekend Manager to post, leading to a lapse in updates. The Administrator realized the error after reviewing the postings.
The facility failed to provide timely access to medical records for two residents after requests were made by the residents and their POAs. For one resident, the records were delayed due to the process involving the Corporate Office and third-party departments. For the other resident, the delay was due to late receipt of therapy records. The facility's policy required records to be provided within two working days, which was not met.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a urinary catheter. During an observation, a CNA was seen emptying a urinary catheter drainage bag without wearing a gown, and there was no EBP sign or PPE cart present. Interviews with staff revealed a lack of adherence to EBP protocols, and the Infection Control Nurse admitted to missing the urinary catheter during rounds. The resident's care plan and physician's order confirmed the need for EBP, but these measures were not implemented.
Medications Not Administered or Monitored as Ordered
Penalty
Summary
The facility failed to ensure a resident received medications in accordance with physician orders and professional standards. Resident D had diagnoses including urine retention, hypertension, osteomyelitis, chronic kidney disease, heart failure, and edema, and was dependent for toileting with bowel and bladder incontinence. The resident’s admission MDS indicated intact cognition, receipt of IV medications, and use of a central line. The record showed multiple ordered medications were not administered as scheduled, including carvedilol 3.125 mg twice daily, midodrine HCL 10 mg three times daily, vancomycin 250 mg four times daily, and enoxaparin sodium 40 mg daily. The MAR documented missed doses of carvedilol on two consecutive days, missed doses of midodrine on multiple scheduled administrations, missed doses of vancomycin on several scheduled times, and missed doses of enoxaparin on several days. For these omissions, there was no documentation explaining why the medications were not given and no documentation that the physician had been notified. In some instances, nurses’ notes stated the medication was on order or re-ordered, and the Pharmacy EDK inventory list indicated the medications were available in the EDK. The DON acknowledged during interview that the medications had not been administered as ordered and stated he was not sure whether the medications were unavailable in the EDK or why the EDK had not been used. The record also showed delayed transcription and administration of hospital re-admission orders for metoprolol succinate ER 25 mg daily and empagliflozin 10 mg daily, with the orders not transcribed until two days later and first doses given after the delay, without documentation that the resident or physician had been notified. In addition, midodrine HCL 10 mg twice daily was administered on multiple occasions without a blood pressure check when the order required holding the medication if systolic blood pressure was greater than 90. The DON and Nurse Consultant acknowledged that the medication had been administered with systolic blood pressure over 90.
Missing Completion and Documentation of Ordered Lab Tests
Penalty
Summary
The facility failed to ensure timely laboratory services for two residents when ordered blood and urine/stool tests were not completed, and there was no documentation explaining why the tests were not done or that the physician had been notified. One resident had diagnoses including urine retention, hypertension, osteomyelitis, chronic kidney disease, heart failure, and edema, with an admission MDS showing intact cognition, dependence for toileting, bowel and bladder incontinence, IV medications, and a central line. Multiple physician orders were entered for a CBC, CRP, CMP, ESR, vitamin B1 level, stool occult blood test, and a repeat CMP, but the record contained no evidence that these tests were completed or that the physician was informed they were not completed. A second resident with diagnoses including UTI, diabetes mellitus, Parkinson's disease, and dementia had an order for a urinalysis, but there was no documentation that the test was completed, no results in the record, and no documentation that the physician was notified. During interviews, the DON acknowledged the missing documentation for the first resident's lab orders and stated that physician orders entered into the computer go directly to the contracted laboratory company. For the second resident, the DON stated the urinalysis had been documented as collected but the lab had not picked it up. The facility's current lab policy stated that the lab was integrated with the electronic medical record and results would be downloaded to the record.
Incomplete bladder scan documentation
Penalty
Summary
The facility failed to ensure resident records were accurate and complete for bladder scan documentation for 2 of 4 residents reviewed. Resident D had diagnoses including urine retention, hypertension, osteomyelitis, chronic kidney disease, heart failure, and edema. An admission MDS dated 9/22/25 indicated intact cognition, no behaviors, and dependence for toileting with bowel and bladder incontinence. A physician order dated 9/24/25 directed daily post-void bladder scans for one week, with results to be documented and the physician's office notified daily. The MAR showed the scans were completed on day shift from 9/25 through 9/30/25, but there was no documentation of the amount of urine found on the MAR or in Nurses' Progress Notes, and no Bladder Scan Evaluations were completed. The Unit Manager stated the scans were completed and the physician's office was e-faxed, and the DON stated there was no documentation of the amount of urine found except for one entry of 240 cc on 9/25/25 at 7:02 p.m. Resident E had diagnoses including urinary tract infection, diabetes mellitus, Parkinson's disease, and dementia. An admission MDS dated 11/2/25 indicated moderately impaired cognition and no behaviors. A physician order dated 10/31/25 directed bladder scans every eight hours for three days, and the MAR scheduled scans at 6:00 a.m., 2:00 p.m., and 10:00 p.m. from 11/1/25 through 11/3/25. The MAR showed initials and check marks indicating scans were completed on 11/1/25 at 2:00 p.m. and 10:00 p.m. and on 11/2/25 at 6:00 a.m. and 2:00 p.m., but the amount of urine found was not documented. There was no documentation in Nurses' Progress Notes and no Bladder Evaluation forms completed. The DON stated there was no documentation of the amount of urine found during the scans, and the facility bladder scan policy indicated the amount of urine found during the scan would be recorded.
Failure to Use Required PPE During EBP Care
Penalty
Summary
The facility failed to ensure correct PPE was used by staff members when providing care to residents on Enhanced Barrier Precautions (EBP). During an observation, CNA 1 was providing incontinence care to Resident F, who had a magnetic EBP sign on the door and a PPE bin outside the room. CNA 1 wore gloves but did not don a gown while providing care. After the care was completed, CNA 1 stated she should have worn a gown. Resident F’s record showed diagnoses including a gastrostomy tube, and the care plan and physician’s order indicated EBP was required, with gowns and gloves to be worn during high-contact resident care. During another observation, CNA 2 was in Resident J’s room after transferring the resident from bed to wheelchair and making the bed. Resident J’s door also displayed an EBP sign, and CNA 2 was wearing gloves but not a gown. CNA 2 stated she should have worn a gown while providing care. Resident J’s record showed diagnoses including peripheral vascular disease, and the care plan and physician’s order indicated EBP was required. The record also showed a midline IV catheter and an order for treatment and dressing for an open area on the right toe. The facility’s EBP policy stated that residents with wounds, indwelling medical devices, and feeding tubes were to have EBP utilized during high-contact care, with gowns and gloves worn.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential or actual accidents. Specific actions or inactions leading to this deficiency include the presence of hazards in the area and a lack of appropriate oversight by staff, as directly observed by surveyors.
Crash Cart Oxygen Tank Found Empty
Penalty
Summary
The facility failed to ensure that oxygen was available on the crash cart for one of two crash carts reviewed. During an observation of the A Wing crash cart near Room A160, it was found that the oxygen tank on the cart was empty. The A Wing Unit Manager confirmed the oxygen tank was empty and was unsure how often the oxygen tank level was checked, although she stated that crash cart supplies were checked daily. The DON later indicated that the crash cart oxygen should be checked daily. Facility policy required that oxygen on the crash cart be checked nightly.
Failure to Update and Implement Wound Care Orders
Penalty
Summary
The facility failed to ensure that treatment orders were updated and completed as ordered for a resident with multiple non-pressure related skin conditions. The resident had a history of orthopedic aftercare following surgical amputation, chronic osteomyelitis, cellulitis of both lower limbs, and type 2 diabetes mellitus. The resident was cognitively intact and had documented skin integrity impairment, with care plan interventions requiring evaluation and treatment per physician orders. Initial physician orders specified wound care regimens for various areas of the right foot, including cleansing, application of Xeroform, and dressing changes on specific days. Subsequent to wound care and podiatry appointments, new orders were provided, including the use of Iodosorb, Betadine, and changes to dressing frequency and materials. These updated orders were documented in after-visit summaries and progress notes but were not transcribed into the physician order summary or implemented in the medication and treatment administration records. The wound care nurse acknowledged entering the updates in progress notes but not updating the official physician order summary, resulting in the failure to carry out the new wound care instructions as directed.
Failure to Verify G-Tube Placement, Check Residuals, and Document Care During Tube Feedings
Penalty
Summary
The facility failed to ensure proper care and documentation for residents with gastrostomy tubes (G-tubes) during tube feeding administration. In one instance, an LPN administered a bolus G-tube feeding to a resident without checking tube placement or residual immediately prior to the feeding, as required by physician orders and care plan interventions. Additionally, the LPN did not flush the G-tube with water after the feeding was completed, contrary to the physician's order for scheduled flushes. The resident's diagnoses included gastrostomy status, dysphagia, and protein calorie malnutrition, and the care plan specified the need to check tube placement and residual volume per protocol and record the findings. For another resident, the facility failed to document the amount of G-tube residual on multiple dates, despite a physician's order to check and record residual every shift. The resident's care plan also required checking tube placement and residual volume per protocol. The medication administration record (MAR) for the relevant month did not include a place to document residuals, and the DON confirmed the omission during an interview. A third resident received a bolus tube feeding without verification of tube placement or checking for residual prior to administration. The nurse administering the feeding acknowledged not performing these checks, despite the facility's policy requiring verification of placement and residual. The resident's care plan and physician orders included instructions for enteral nutrition and specified the need to check tube placement and residual volume per protocol. The facility's policy on tube feeding also required checking tube placement and flushing the tube with water at the end of the feeding.
Failure to Label, Date, and Properly Store Food Items in Kitchen
Penalty
Summary
Surveyors observed multiple instances of improper food storage and labeling in the facility's main kitchen during an initial sanitation tour. In the dry storage room, there was a large unlabeled storage bin containing a white powder and an unlabeled container partially filled with yellow liquid. In the walk-in cooler, a partially full, unlabeled squeeze bottle with a red/brown substance was found, along with an uncovered bucket of cut-up potatoes in water and trays of desserts that were uncovered and unlabeled. The walk-in freezer contained an open, unlabeled bag of fish patties and an open, unlabeled bag of corn. Additionally, in the food prep area, both a large plastic bin and a smaller plastic container filled with white powder were found to be unlabeled. During an interview, the Kitchen Manager confirmed that all food items should have been labeled and dated when opened, and that uncovered items should have had lids. Facility policies provided by the Kitchen Manager required that bulk foods removed from original packaging be labeled with the common name, date opened, and use-by or discard date, and that opened products be tightly covered and labeled. These policies were not followed, resulting in the cited deficiency. The issue had the potential to affect all 86 residents who received food from the kitchen.
Failure to Assess and Monitor Bruises, Constipation, Edema, and Medication Administration Parameters
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for multiple residents. For two residents on anticoagulant therapy, staff did not assess or monitor bruises as required by care plans and facility policy. In one case, a resident with a history of diabetes, sepsis, and heart disease was observed with reddish/purple discoloration on the forearm, but there was no documentation or assessment of this new skin condition. Another resident was observed with multiple bruises on the hands and arm, attributed to lab draws, but again, there was no documentation or monitoring of these bruises as required. For a resident receiving opioid pain medication following a surgical amputation, staff failed to adequately monitor and document signs and symptoms of constipation. The resident experienced several days without a bowel movement, followed by vomiting and abdominal pain, which led to further medical intervention. Documentation was incomplete, and the facility's bowel protocol was not followed, as there was a lack of timely assessment and intervention for constipation related to opioid use. Additionally, the facility did not properly monitor or assess edema for a resident with end stage renal disease and hypertension. The use of a compression glove for hand swelling was not clearly documented, and there was no care plan or intervention specific to the right hand edema. The documentation on the use of the compression glove was unclear, with no explanation of the symbols used to indicate skin assessment findings. Furthermore, for another resident with cardiovascular conditions, medications intended to be held for low blood pressure were administered outside of the prescribed parameters on multiple occasions, contrary to physician orders.
Failure to Assess and Authorize Self-Administration of Nebulizer Treatments
Penalty
Summary
A resident with diagnoses including COPD, chronic respiratory failure with hypoxia, and dementia was observed receiving a nebulizer treatment alone in his room. The resident reported that staff initiated the nebulizer treatment but did not remain in the room, and he independently removed the face mask and stored it in his nightstand when he believed the treatment was complete. Review of the resident's record showed moderate cognitive impairment and a need for partial/moderate assistance with activities of daily living and transfers. The most recent self-administration assessment did not indicate the resident was safe to self-administer nebulizer treatments, and there was no physician's order authorizing self-administration. The DON confirmed that the resident had not been evaluated for self-administration of nebulizers, and facility policy required a physician order and assessment of the resident's ability prior to self-administration.
Failure to Notify Physician of Changes in Condition and Medication Administration
Penalty
Summary
The facility failed to ensure timely and appropriate notification of physicians regarding significant changes in residents' conditions and medication administration. For one resident with type 2 diabetes and end stage renal disease, blood sugar readings exceeded 400 on two occasions, but there was no documentation that the physician or nurse practitioner was notified as required by the physician's order. Another resident with dementia, diabetes, hypertension, and acute kidney failure had a blood pressure medication withheld on two occasions without any documented notification to the physician or nurse practitioner, despite the absence of parameters for holding the medication. Additionally, a third resident with congestive heart failure and diabetes had insulin doses either refused or held, but there was no documentation that the physician was informed of these missed doses. In each case, interviews with the Director of Nursing confirmed that the appropriate notifications to the physician or nurse practitioner were not made as required by facility policy and physician orders.
Inaccurate MDS Assessment for Hospice Resident
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for a resident with a terminal prognosis who was receiving hospice care. Record review showed that the resident had diagnoses including hypertension, atrial fibrillation, and Alzheimer's disease, and had been admitted to hospice services with a documented terminal end stage prognosis and a life expectancy of six months or less. Despite this, the resident's quarterly MDS assessment indicated that the resident was not receiving hospice care and did not have a terminal condition. This discrepancy was confirmed during interviews with MDS nurses, who acknowledged the resident was on hospice and had a terminal prognosis.
Failure to Develop Comprehensive Care Plan for Edema and Oxygen Use
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing all of a resident's needs, specifically for edema, compression glove use, and oxygen therapy. Observation revealed that the resident was using oxygen via nasal cannula at a flow rate of 1.5 liters, had a slightly swollen right hand, and a compression glove was present at the bedside. The resident reported using oxygen, typically at 2 liters, and wearing the compression glove on her right hand only at night. Record review showed diagnoses of hypertension, end stage renal disease, and type 2 diabetes mellitus. The most recent MDS assessment did not indicate oxygen therapy, and the existing care plan addressed only renal insufficiency and general edema prevention, without specific interventions for right hand edema, compression glove use, or oxygen therapy. There was no current care plan in place for these specific needs at the time of the survey.
CNA Operates Tube Feeding Pump Outside Scope of Practice
Penalty
Summary
A certified nursing assistant (CNA) placed a tube feeding pump on hold for a resident receiving enteral nutrition, prior to performing incontinence care and lowering the head of the bed. The resident had a gastrostomy, adult failure to thrive, dysphagia, and was dependent on tube feeding for the majority of her nutrition. The resident also had significant cognitive impairment, with both short and long term memory problems and severely impaired decision-making abilities. According to the Indiana State Department of Health Nurse Aide Curriculum, CNAs are not permitted to operate tube feeding pumps and must seek a nurse's assistance to turn off or resume the pump. The CNA's action of placing the pump on hold was observed during care, and a nurse later resumed the feeding after care was completed.
Failure to Assist Resident in Accessing Vision Services
Penalty
Summary
A resident with diagnoses including COPD, chronic respiratory failure with hypoxia, and dementia, who required partial to moderate assistance with activities of daily living and transfers, reported being unable to see with his current glasses and not having been evaluated by an eye doctor since before admission to the facility. The resident's daughter stated she had requested assistance from the facility's social worker to arrange an eye doctor appointment, but was told that seeing an eye doctor was not part of the resident's care and that the facility could not make such arrangements. Review of the resident's record revealed no documentation of vision or eye care. The Director of Social Services later confirmed that residents should be able to see an eye doctor if needed and that the facility would assist in making those arrangements.
G-Tube Flush Administered Incorrectly by Syringe Plunger
Penalty
Summary
A deficiency was identified when a licensed practical nurse (LPN) failed to administer a gastrostomy tube (G-tube) flush by gravity for a resident during medication administration. The LPN prepared the resident's medications by crushing each pill and diluting them in water, then placed the G-tube syringe into a medication cup, drew up 30 cc of water, and pushed the water down the G-tube using the syringe plunger, rather than allowing it to flow by gravity as required. The remaining medications and flushes were administered by gravity. The LPN later acknowledged that the G-tube flush should have been administered by gravity, in accordance with the facility's policy, which specifies that water and medications should be allowed to flow down the tube via gravity.
Failure to Ensure Physician Orders and Care Plan for Oxygen Therapy
Penalty
Summary
A resident with diagnoses including hypertension, end stage renal disease, and type 2 diabetes mellitus was observed on two occasions using oxygen via nasal cannula at a flow rate of 1.5 liters, while the resident reported it was usually set at 2 liters. Review of the resident's medical record revealed no current physician's order for oxygen therapy and no care plan addressing oxygen use. The Admission MDS assessment indicated the resident was moderately cognitively impaired and did not receive oxygen therapy. The facility's policy required that residents on oxygen have physician orders specifying the route and liter flow, but no such orders were found in the resident's chart. The DON confirmed the absence of current oxygen orders for the resident.
Medication Error Rate Exceeds Acceptable Threshold During Insulin Administration
Penalty
Summary
A medication error rate of 7.69% was identified during medication administration observations, exceeding the acceptable threshold of less than 5%. Specifically, two medication errors were observed out of 26 opportunities. One incident involved an LPN preparing and administering insulin to a resident with type 2 diabetes mellitus. The LPN failed to prime the insulin pen before injection, contrary to facility policy, and administered 20 units of Lantus insulin instead of the physician-ordered dose of 18 units. The LPN acknowledged not priming the insulin pen prior to administration, stating that pens were only primed when first opened. The facility's insulin administration policy requires priming the pen before each use to ensure proper dosing and avoid injecting air. The errors were brought to the attention of the Director of Nursing, and the relevant policy was reviewed.
Medications Left Unattended on Medication Cart
Penalty
Summary
A deficiency occurred when an LPN prepared medications for a resident and placed a pill card of multivitamin, a pill card of ferrous sulfate, and a medication cup containing the resident's morning medications on top of the medication cart. The LPN then left the medication cart unattended and out of sight while she went to the Nurse's Station, leaving the medications unsecured on the cart. The medications remained unattended until the LPN returned several minutes later. During an interview, the LPN acknowledged that medications should not have been left unattended. The Director of Nursing was informed of the incident, and a medication storage policy was requested, but no further information was provided.
Failure to Assist Resident in Obtaining Dental Care
Penalty
Summary
The facility failed to assist a resident in obtaining necessary dental care. The resident, who had diagnoses including COPD, chronic respiratory failure with hypoxia, and dementia, reported that his dentures did not fit well and made chewing difficult. He had not been evaluated by a dentist since before his admission. The resident's daughter stated that when she requested assistance from the social worker to arrange a dental appointment, she was told that dental care was not part of the resident's care at the facility and that arrangements could not be made. Review of the resident's record showed no documentation of dental care provided. The Director of Social Services later confirmed that the resident should be able to see a dentist if needed and that the facility would help make those arrangements.
Incomplete Medication Documentation and Missing Administration Parameters
Penalty
Summary
The facility failed to ensure complete and accurate medical record documentation for a resident with diagnoses including diabetes and heart failure. A physician's order for Droxidopa every 8 hours was present, but the April Medication Administration Record (MAR) had blank documentation boxes for three scheduled doses, despite the Assistant Director of Nursing stating the medication was administered but not recorded. Additionally, a physician's order for Midodrine every 8 hours as needed for hypotension lacked specific blood pressure parameters for administration, and the Director of Nursing confirmed that no such parameters could be found in the record.
Failure to Timely Notify Physician of Medication Unavailability
Penalty
Summary
The facility failed to notify the physician in a timely manner regarding the unavailability of a medication for a resident diagnosed with heart failure, gout, muscle weakness, and COPD. The resident was prescribed Vericiguat, a medication for chronic heart failure, to be taken daily. However, the medication was not available, and the pharmacy was aware of this issue. Despite this, there was no documentation indicating that the physician was informed of the delay until four days later, on February 16, 2025. The Director of Nursing (DON) confirmed that the physician should have been notified of the medication delay after 48 hours of non-receipt. The facility's policy required staff to contact the physician for an alternative if a medication was unavailable. The DON only received notification from the pharmacy about the medication's high cost and the need for approval on February 18, 2025, which he approved the same day. The resident's family was initially asked to supply the medication due to its cost, but this was later resolved without their involvement.
Failure to Use Correct PPE for Resident Under EBP
Penalty
Summary
The facility failed to ensure correct Personal Protective Equipment (PPE) usage by a staff member, CNA 1, when providing care to a resident, Resident G, who was under Enhanced Barrier Precautions (EBP). During an observation, CNA 1 was seen assisting Resident G without wearing a gown, despite the presence of a container with PPE and a sign indicating the need for EBP. Resident G, who had a feeding tube, was lying in bed and required high-contact care, which necessitated the use of a gown and gloves according to the facility's EBP policy. CNA 1 acknowledged the need for a gown after the care was provided. Resident G's medical record indicated a diagnosis of stroke and a physician's order for EBP due to the feeding tube. This incident was related to a complaint investigation.
Failure to Implement Pressure Ulcer Care Plan
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing for a resident with a pressure ulcer. During observations, it was noted that the resident's heels were resting directly on a regular mattress instead of being offloaded as required. Heel protectors were not in use, and a low air loss mattress intended for pressure reduction was found on the floor instead of on the resident's bed. Additionally, during incontinent care, a skin barrier cream was not applied as ordered, which was part of the care plan to prevent further skin breakdown. The resident, identified as having a deep tissue injury (DTI) on the right heel, had a care plan that included the use of an air mattress and offloading devices to prevent pressure on the heels. Despite these orders, the interventions were not implemented, and the treatment for the DTI was not completed as prescribed. The resident's medical history included diabetes mellitus, peripheral vascular disease, and stroke, which could contribute to the risk of pressure ulcers. The facility's failure to adhere to the care plan and physician's orders resulted in inadequate care for the resident's pressure ulcer.
Failure to Use Correct PPE for Resident Under Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that correct Personal Protective Equipment (PPE) was used by staff members when providing care to a resident who was under Enhanced Barrier Precautions (EBP). During an observation, two Licensed Practical Nurses (LPNs) entered the room of a resident to provide incontinent care without donning gowns, despite the requirement for PPE due to the resident's EBP status. The LPNs only wore gloves while assisting the resident, which was not in compliance with the facility's EBP policy that mandates the use of both gowns and gloves during high-contact resident care. The resident in question had a medical history that included diabetes mellitus, peripheral vascular disease, and stroke, and was noted to have a Deep Tissue Injury (DTI) on the right heel. The facility's policy required EBP PPE for residents with wounds, including any skin opening that required a dressing. The LPNs acknowledged the presence of a sign indicating the need for PPE and the availability of PPE in the room, but failed to utilize it. This oversight occurred despite a physician's order specifying the use of EBP due to the resident's wound condition.
Failure to Notify Responsible Party of Significant Changes in Resident's Status
Penalty
Summary
The facility failed to promptly notify the responsible party of a resident after significant changes in the resident's medical status, including the placement of an intravenous (IV) site, changes in medications, and medication times. The resident, who was cognitively impaired and had multiple diagnoses including dementia, acute kidney failure, and chronic kidney disease, was admitted to the facility and later discharged home. During the resident's stay, new orders for IV fluids were received, and a peripheral inserted central catheter (PICC) line was inserted after attempts to place a peripheral IV failed. Additionally, there were changes in the resident's medication regimen, including a decrease in Gabapentin dosage and the addition of Lyrica, as well as the administration of a medication to lower high potassium levels. Despite these significant changes, there was no documentation indicating that the resident's responsible party was informed about the PICC line insertion, the administration of IV fluids, the changes in medication, or the treatment for high potassium levels. The Chief Nursing Officer confirmed the lack of documentation regarding the notification of the responsible party. The facility's policy required that nursing staff notify the resident's physician of significant changes and subsequently inform the resident and their family, documenting these communications in the resident's record. This deficiency was identified in relation to a specific complaint.
Failure to Assist Resident with Personal Hygiene Needs
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs) were completed for a resident who required assistance, specifically related to the maintenance of fingernails. Resident F, who was cognitively intact and required supervision with personal hygiene, was observed with long fingernails on multiple occasions. The resident expressed that they did not have nail clippers and would have managed their nails themselves if they had the tools. Additionally, the resident indicated that staff had not offered assistance in trimming their nails. Despite the resident's request for help, their fingernails remained untrimmed until a later observation confirmed they had been cut. The resident's medical history included a fracture of the left femur, osteoarthritis, and lack of coordination, which may have contributed to their need for assistance with personal hygiene tasks.
Failure to Monitor Bruising in Resident on Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure proper assessment and monitoring of bruising for a resident who was on anticoagulant therapy. The resident, who was cognitively intact, had a history of orthopedic aftercare following surgical amputation, cellulitis, type 2 diabetes, and atherosclerotic heart disease. They were observed with reddish/purple discolorations on their forearms and hands. Despite having a physician's order for skin checks twice a week and being on Rivaroxaban for DVT prevention, there was no care plan addressing the bruising or anticoagulant use. Additionally, the skin assessment was marked as completed without documentation of any new skin concerns.
Failure to Maintain and Monitor IV Catheters for Two Residents
Penalty
Summary
The facility failed to ensure proper maintenance and monitoring of peripheral intravenous (IV) catheters for two residents, leading to deficiencies in their care. Resident G had a peripheral IV catheter in the right upper arm, with physician's orders to receive Meropenem intravenously and flush the IV with normal saline before and after medication administration. However, the Medication Administration Record (MAR) did not reflect the administration of the saline flushes as routine, leading to a lack of documentation of the flushes from November 6 to November 14, 2024. The Chief Nursing Officer acknowledged the error, indicating the flush order was incorrectly listed as PRN (as needed) instead of routine. Resident D experienced discomfort due to an IV inserted in the deltoid, which was found to be bloody and red. The resident's record indicated attempts to insert a peripheral IV, which infiltrated, leading to the insertion of a midline by a PICC line nurse. However, there were no physician's orders to monitor the PICC line site for infection or to maintain patency with saline flushes. The Chief Nursing Officer confirmed the absence of such orders. The facility's policy required monitoring of IV sites for signs of infiltration, but this was not adhered to, resulting in inadequate care for Resident D.
Incomplete Documentation of Wound Care and Fall Evaluations
Penalty
Summary
The facility failed to ensure complete and accurate documentation of clinical records for two residents. For Resident K, the Treatment Administration Record (TAR) did not reflect that wound care treatments were completed as ordered on specific dates in October 2024. Although the Wound Nurse indicated that the treatments were performed, they were not signed off in the TAR, leading to incomplete documentation. Resident K had multiple diagnoses, including a surgical wound and a Stage 3 pressure ulcer, requiring specific wound care interventions. For Resident E, the facility did not properly document falls and related evaluations. The resident, who had dementia and was at high risk for falls, experienced a fall that was not immediately followed by a completed fall risk evaluation. The Chief Nursing Officer (CNO) noted that the evaluation was completed late and not initially included in the resident's clinical record. The fall occurred on a weekend, and the CNO had to facilitate the completion of the evaluation over the phone with the nurse on duty. The facility's fall protocol required evaluations to be completed immediately after a fall, which was not adhered to in this case.
Failure to Document and Communicate Resident Transfer to ER
Penalty
Summary
The facility failed to provide and document sufficient information for a resident being transferred to the hospital emergency room (ER). The deficiency involved Resident E, who had a diagnosis of metabolic encephalopathy. On the date of the incident, the resident was discharged from the facility, but the discharge status was not listed on the Minimum Data Set assessment. There was no documentation in the Nurses' Progress Notes indicating a change of condition, transfer to the ER, or discharge from the facility. Additionally, there was no Transfer Form or Discharge Form completed. The hospital ER notes indicated the resident lost consciousness during a transfer from bed to chair, but there was no prolonged loss of consciousness. The Director of Nursing (DON) confirmed that a family member called 911 for the transfer, and there was no documentation of the change of condition or completion of a transfer sheet. The DON was unable to verify if any paperwork was sent with the resident or if the hospital ER was notified with the resident's information.
Inaccurate MDS Assessments for Falls and Medications
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately completed for two residents, leading to discrepancies in recorded information regarding falls, medications, and behaviors. Resident G's Admission MDS assessment inaccurately indicated no behaviors, no falls, and no antipsychotic medication use, despite multiple falls documented in the Nurse's Progress Notes and the administration of olanzapine for bipolar disorder with behaviors. The resident experienced several falls and exhibited aggressive behaviors, which were not reflected in the MDS assessment. An interview with MDS LPN 2 confirmed that the Admission MDS had not been coded correctly. Similarly, Resident J's Admission MDS assessment incorrectly reported no falls since admission, although a Nurse's Progress Note documented an unwitnessed fall. The Director of Nursing was informed of the incorrect MDS, but no further information was provided. These inaccuracies in the MDS assessments were identified during a review related to a specific complaint, highlighting the facility's failure to maintain accurate resident assessments.
Failure to Implement Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement individualized care plans for two residents, leading to deficiencies in care. Resident J, who had a left knee immobilizer due to a fracture, developed a pressure sore that began as a blister. Observations revealed that the immobilizer was not properly managed, as it slid down and caused pressure issues despite the use of padding. The facility did not have a care plan in place to address the use of the immobilizer and prevent pressure ulcers, as confirmed by the Director of Nursing. Resident G, diagnosed with dementia, exhibited multiple episodes of behavioral issues over several days. The Medication Administration Record documented these episodes and the interventions attempted, such as redirection and one-on-one care. However, there was no care plan to address the resident's behaviors, and the outcomes of interventions were inconsistently documented. The Social Service Director confirmed the absence of a care plan for managing Resident G's behaviors.
Failure to Administer Antibiotics and Monitor Blood Glucose Levels
Penalty
Summary
The facility failed to provide necessary care and services for a resident with diabetes mellitus and an abdominal wall abscess. The resident was prescribed ceftriaxone sodium, an antibiotic, to be administered once daily for seven days, but it was not given on one of the days, resulting in only six days of treatment. Additionally, another antibiotic, cephalexin, was not administered as ordered for a urinary tract infection. Furthermore, the resident's blood glucose levels were not monitored as required, and insulin was not administered according to the sliding scale protocol. The physician was not notified of elevated blood glucose levels, which were recorded multiple times above the threshold of 351, as specified in the physician's order. The Director of Nursing confirmed during interviews that the antibiotics were not administered and blood glucose levels were not obtained as ordered. There was also no documentation indicating that the physician had been notified of the elevated blood glucose results. These deficiencies were identified during a review of the resident's records and interviews conducted on specific dates, and they relate to complaints IN00438865 and IN00439585.
Failure to Investigate Fall and Implement Interventions
Penalty
Summary
The facility failed to conduct a thorough investigation of a fall involving a resident with severe cognitive impairment and high fall risk. The resident, diagnosed with dementia, was found on the floor and claimed to have wanted to see the world from the bottom up, denying a fall. Despite this, the investigation did not determine the root cause of the fall or document when the resident was last observed before the incident. The care plan had indicated that potential causes of falls should be identified and addressed, but this was not done. The Director of Nursing (DON) and an LPN involved in the incident did not provide a clear account of the circumstances leading to the fall. The facility's fall prevention policy lacked a post-fall protocol, and the only intervention noted was the placement of a fall mat by the bedside. The investigation and documentation were insufficient, as they did not include critical details such as the last observation time of the resident or a comprehensive analysis of the fall's root cause.
Inadequate Management of Dementia-Related Behaviors
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, leading to ongoing behavioral issues without proper input from the Interdisciplinary Team (IDT) and Social Services. The resident, identified as having severe cognitive impairment and requiring assistance with mobility, exhibited behaviors such as restlessness, exit-seeking, verbal abuse, and physical aggression. Despite these behaviors, there was no care plan in place to address them, and interventions were not consistently documented or attempted before administering medication. The resident's medical records indicated multiple instances of behavioral episodes, including attempts to leave the facility, verbal hostility, and physical aggression towards staff. Although there were physician's orders for non-pharmacological interventions prior to administering PRN psychotropic medications, these interventions were often not documented or attempted. The facility's failure to document specific targeted behaviors and the outcomes of interventions further compounded the issue, as it hindered the development of a person-centered care plan. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's behaviors. The Social Service Director acknowledged the absence of a care plan and social service involvement, while the Director of Nursing admitted that not all behaviors were documented. The facility's behavioral management policy required monitoring and documentation of behaviors to develop individualized care plans, but this was not adhered to, resulting in inadequate management of the resident's dementia-related behaviors.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to ensure the correct use of Personal Protective Equipment (PPE) by staff members during wound care treatments, specifically involving two LPN Wound Nurses. During an observation, it was noted that there was no sign on Resident J's door indicating the need for Enhanced Barrier Precautions (EBP), despite the resident having pressure sores on the left heel and left posterior ankle. The LPN Wound Nurses applied gloves but did not implement EBP, as one nurse incorrectly stated that EBP was only necessary if the wounds had drainage. This oversight was contrary to the facility's policy, which required EBP for any wounds needing a dressing, potentially affecting 13 residents who required wound treatments.
Inaccurate Nurse Staffing Information Posting
Penalty
Summary
The facility failed to ensure that the posted Nurse Staffing Information was current and accurately reflected only the staff scheduled for Long Term Care. On August 5, 2024, it was observed that the Nurse Staffing Information posted at the Receptionist Desk was dated August 1, 2024, indicating it had not been updated for several days. During an interview, the Director of Nursing mentioned that the posting information was left in a binder for the Weekend Manager to post, suggesting a lapse in the updating process. Additionally, a review of the schedules and postings for July 2024 revealed that the Nurse Staffing Information included staff from Assisted Living, which was not intended. The Administrator acknowledged this oversight during an interview on August 6, 2024, indicating that they had just realized the inclusion of Assisted Living staff in the postings. This deficiency was related to a specific complaint, IN00439585.
Delayed Access to Medical Records for Residents
Penalty
Summary
The facility failed to provide timely access to medical records for two residents, G and H, after requests were made by the residents and their Power of Attorneys (POAs). For Resident G, the request for the complete medical record was made on 5/31/24, but the records were not received until 6/7/24. The delay was attributed to the process of scanning the request to the Corporate Office, where the Legal Department reviewed it before contacting the facility for release. Additionally, the facility had to wait for therapy and other third-party departments to provide their records, as they were not accessible through the facility's system. Similarly, Resident H's medical records were requested on 5/14/24 and were not received until 5/19/24. The Business Office Manager indicated that the delay was due to not receiving therapy records until 5/17/24, which were then printed and added to the medical record on 5/19/24. The facility's policy, dated 5/2023, stated that records should be provided within two working days of the request, which was not adhered to in these cases. This deficiency was related to a complaint identified as IN00431978.
Failure to Implement Enhanced Barrier Precautions for Resident with Urinary Catheter
Penalty
Summary
The facility failed to ensure the correct use of Personal Protective Equipment (PPE) by a staff member when handling a urinary catheter drainage bag for a resident under Enhanced Barrier Precautions (EBP). During a random observation, a Certified Nursing Assistant (CNA) was seen emptying a urinary catheter drainage bag without wearing a gown, despite the resident having a urinary catheter, which required EBP. The CNA acknowledged the lack of a gown and indicated that she believed there should have been a sign on the door and a PPE cart available if the resident was under EBP. However, there was no EBP sign or PPE cart present. Interviews with other staff members, including Licensed Practical Nurses (LPNs) and the Infection Control Nurse, revealed a lack of adherence to EBP protocols. The LPNs indicated that residents with certain conditions, such as urinary catheters, should be placed under EBP, with appropriate signage and PPE available. The Infection Control Nurse admitted to missing the presence of the urinary catheter during rounds and stated that the admitting nurse was responsible for initiating EBP signage and PPE. The resident's care plan and physician's order confirmed the need for EBP due to the urinary catheter, but these measures were not implemented, leading to the deficiency.
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 1,243 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) |
|---|---|---|---|---|
| Great Lakes Healthcare Center | 1 mi | ★★★★★ | 34 | 0 |
| Dyer Nursing And Rehabilitation Center | 1.2 mi | ★★★★★ | 8 | 0 |
| Rehabilitation Center At Hartsfield Village | 3.5 mi | ★★★★★ | 11 | 0 |
| Munster Med-inn | 4.4 mi | — | 44 | 2 |
| St James Wellness Rehab Villas | 5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.