Inspection Reports for
Cedarhurst of Dyer

The investigation was related to complaints about medication errors, incomplete lab testing, inadequate medical record documentation, and improper infection control practices. The findings were substantiated with documentation and interviews confirming the issues.

The facility failed to administer medications timely and as ordered, did not complete ordered laboratory tests, lacked accurate documentation of bladder scan results, and failed to ensure staff used correct personal protective equipment during care for residents under Enhanced Barrier Precautions.

The complaint investigation (2573709) included issues with wound care order updates, resident elopement risk and safety, and crash cart oxygen availability. Immediate jeopardy was identified related to elopement on 7/27/25 and removed on 7/30/25 after corrective actions.

The facility failed to update wound care treatment orders for one resident, failed to prevent elopement of a resident with dementia resulting in immediate jeopardy that was later removed, and failed to ensure oxygen was available on one of two crash carts.

This citation relates to Complaint IN00459895.

The facility failed to ensure proper checking of G-tube placement and residuals prior to bolus feedings and did not flush feeding tubes after feedings as ordered. Documentation of residual amounts was also incomplete for three residents reviewed.

The facility was found deficient in multiple areas including medication administration errors, failure to notify physicians of changes in resident conditions, incomplete care plans, improper respiratory care, inadequate monitoring of skin conditions, failure to assist residents in accessing vision and dental care, improper food labeling and storage, and incomplete medical record documentation.

This citation relates to Complaint IN00450991.

The facility failed to notify the physician timely about a delayed medication for one resident and failed to ensure correct Personal Protective Equipment (PPE) use by staff when providing care to a resident under Enhanced Barrier Precautions.

Complaint IN00445933 was substantiated with a state deficiency cited at R273 related to food and nutritional services.

The facility failed to store, serve, and prepare food under sanitary conditions, including dirty food equipment, food crumbs on floors and under appliances, undated food items, food splatter on ceiling tiles, grease buildup on cooking equipment, and improper meat storage. These deficiencies had the potential to affect all 69 residents receiving food from the kitchen.

This citation relates to Complaint IN00450726.

The facility failed to provide appropriate pressure ulcer care for a resident with a deep tissue injury, including failure to use a low air loss mattress as ordered and incomplete treatment. Additionally, staff failed to use correct Personal Protective Equipment (PPE) when providing care to the resident under Enhanced Barrier Precautions.

This citation relates to Complaints IN00444812, IN00445480, IN00445567, IN00446247, IN00443720, IN00445316, and IN00446301. The investigation substantiated failures in notification, care assistance, IV catheter management, and clinical documentation.

The facility failed to promptly notify a resident's responsible party of significant changes, ensure activities of daily living assistance, properly assess and monitor IV catheter sites, and maintain complete and accurate clinical records related to falls and treatments. Several residents were affected with minimal harm or potential for harm.

The inspection relates to multiple complaints including IN00438865, IN00439371, and IN00439585, involving issues such as resident transfers, assessment accuracy, care planning, medication administration, fall investigations, staffing postings, behavioral management, and infection control.

The facility was found deficient in multiple areas including failure to document resident transfers, inaccurate Minimum Data Set assessments, incomplete care plans, missed medication administrations, inadequate fall investigations, improper nurse staffing postings, insufficient behavioral management for dementia residents, and improper use of personal protective equipment during wound care.

This citation relates to Complaint IN00431978.

The facility failed to provide residents' medical records in a timely manner for 2 of 3 residents reviewed and failed to ensure correct Personal Protective Equipment (PPE) was used by staff when caring for a resident on Enhanced Barrier Precautions (EBP).

The facility was found deficient in multiple areas including failure to ensure timely physician notification for resident care issues, incomplete service plans, inadequate fire and disaster preparedness drills with local fire department participation, unsanitary food preparation conditions, improper labeling of over-the-counter medications, and incomplete clinical records related to insulin administration.

This citation relates to Complaints IN00424703, IN00426751, IN00424731, and IN00429885.

The facility failed to ensure residents had physician's orders and assessments for self-administration of medications for 5 residents. Additionally, the facility failed to provide adequate ADL assistance including scheduled showers, nail care, facial hair removal, hair washing, and oral care for 5 of 6 residents reviewed.

The inspection was complaint-driven, related to allegations of medication self-administration issues, pain management failures, ADL care deficiencies, infection control lapses, medication errors, and vaccination documentation problems.

The facility was found deficient in multiple areas including failure to ensure physician orders and assessments for medication self-administration, improper pain medication administration, inadequate ADL assistance, incomplete meal documentation, improper medication storage, oxygen therapy errors, medication errors during administration, and failure to properly offer and document COVID-19 vaccinations.

Complaint IN00414849 and Complaint IN00420280 were investigated with no deficiencies related to the allegations cited. The cited deficiency was unrelated to the complaints. The incident involved two residents (Residents H and J) where Resident J was found fondling Resident H's breast without consent. The incident was reported late to IDOH on 12/18/23. The Executive Director acknowledged the failure to timely report and outlined corrective actions including weekly interviews and monitoring to ensure timely reporting of abuse allegations.

No deficiencies were cited related to the allegations in both complaints. However, an unrelated deficiency was cited regarding failure to notify the Indiana Department of Health (IDOH) of an unusual occurrence involving sexual contact between residents unable to give consent.

This citation relates to Complaint IN00422105.

The facility failed to notify a resident's family about behaviors, medication changes, and emergency room transfers. Transfer forms were incomplete for hospital transfers. Dementia care lacked updated care plans, interdisciplinary team input, and effective interventions. Medical records were incomplete, missing documentation of emergency room returns, appeals, and discharge events for residents.

The complaint investigation found that Midodrine was administered incorrectly to Resident F despite orders to withhold the medication if systolic blood pressure was greater than 120. The Director of Nursing confirmed the error.

The facility failed to ensure that a resident was free from unnecessary medications, specifically administering Midodrine when the resident's blood pressure was above the prescribed limit. The Director of Nursing confirmed the medication was given incorrectly despite facility policy requiring vital signs prior to administration.

This Federal tag relates to Complaint IN00407458 for nutritional supplement issues and Complaint IN00408541 for medical record documentation issues.

The facility failed to ensure a resident received nutritional supplements as ordered and failed to document meal consumption for multiple days. Additionally, the facility did not maintain complete and accurate clinical records for a resident's treatment order related to skin condition care.

This Federal tag relates to Complaints IN00403720.

The facility failed to have a physician's order in place for a resident's therapeutic diet for 1 of 3 residents reviewed. The resident received a mechanical soft diet without a proper physician's order from admission until 12/15/22.

The inspection was complaint-driven, addressing multiple complaints including medication self-administration, notification of medication changes, care planning participation, ADL assistance, constipation monitoring, skin condition monitoring, fall follow-up, discharge documentation, respiratory care, pain management, unnecessary medication use, medication errors, and antibiotic stewardship.

The facility was found deficient in multiple areas including failure to ensure residents had proper physician orders and assessments for self-administration of medications, inadequate notification of medication changes to residents, lack of resident participation in care planning, insufficient assistance with activities of daily living, inadequate monitoring of constipation and skin discoloration, failure to complete fall follow-up and discharge documentation, improper respiratory care, inadequate pain management, use of unnecessary medications, medication administration errors, and failure to monitor antibiotic use appropriately.