Inspection Reports for
Dyer Nursing and Rehabilitation Center

This citation relates to Intake 2687036 and Intake 2706590. The investigation found substantiated deficiencies related to missed bathing, delayed incontinence care, medication administration errors, and failure to complete ordered laboratory testing.

The facility failed to ensure residents dependent on staff for ADL assistance received bathing at least twice a week and timely incontinence care. Additionally, the facility did not administer medications as ordered and failed to complete a urinalysis with culture and sensitivity laboratory test as ordered.

The complaint investigation involved missing narcotic medication for Resident M, failure to monitor blood pressure for Resident B as ordered, and improper PPE use by staff for residents under isolation precautions. The narcotic discrepancy led to staff drug testing and termination. The blood pressure monitoring order was not transcribed to the MAR. PPE failures were observed during care of residents with multidrug-resistant organisms.

The facility failed to maintain proper control and documentation of controlled drugs, resulting in missing narcotic medication for a resident. The facility also failed to monitor a resident's blood pressure as ordered and did not ensure correct PPE use by staff for residents under Enhanced Barrier Precautions and Contact Isolation.

This citation relates to Complaint 2584012.3.1-49(j)(2).

The facility failed to timely report Doppler ultrasound results to the physician for one resident, resulting in delayed treatment. Documentation showed no communication of abnormal results from 7/30/25 to 8/5/25, despite the Doppler indicating partial clotting.

This inspection relates to Complaint IN00459057 regarding dignity issues and Complaint IN00459314 regarding inadequate incontinence care.

The facility failed to maintain the dignity of Resident E by allowing food spillage on clothing and exposing the resident's back. The facility also failed to provide timely incontinence care for the same resident, despite care plans and documented assistance requirements.

The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code standards, specifically failing to include required emergency contact information in the Emergency Preparedness Communication Plan and failing to maintain automatic sprinkler systems with proper supervisory signals. The facility had not implemented a systemic plan of correction to prevent recurrence of these deficiencies.

The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code standards, including deficiencies in emergency preparedness arrangements, communication plans, training, fire safety equipment, sprinkler system maintenance, electrical safety, and other building safety issues.

The citation relates to Complaints IN00450533 and IN00451791.

The facility was found deficient in multiple areas including failure to maintain resident dignity, incomplete assessments for medication self-administration, inadequate care planning, insufficient assistance with activities of daily living, lack of PASARR level 2 screening, failure to inform residents of lab results and medication changes, inadequate nutrition assistance and documentation, improper gastrostomy tube care, incorrect oxygen flow rates, medication administration errors, infection control breaches, and failure to provide routine dental services.

Complaint IN00450533 - Federal/State deficiencies related to the allegations are cited at F677. Complaint IN00451227 - No deficiencies related to the allegations are cited. Complaint IN00451791 - Federal/State deficiencies related to the allegations are cited at F677 and F684.

The facility was found deficient in multiple areas including resident rights, medication administration, care planning, ADL care, infection control, oxygen therapy, and other regulatory requirements. Several residents had unmet care needs, medication errors, and incomplete documentation.

This citation relates to Complaints IN00450533 and IN00451791. The complaints involved failure to assist residents with ADLs, medication administration errors, and inadequate treatment and monitoring of skin conditions and changes in resident condition.

The facility failed to ensure timely assistance with ADLs such as feeding, bathing, oral care, and nail care for multiple residents. Insulin administration and blood sugar documentation were incomplete. Treatments and monitoring for skin excoriations, bruises, edema, and changes in condition were inadequate or missing. Several residents did not receive scheduled showers or personal hygiene care. A resident with respiratory distress was not promptly assessed or treated.

The inspection relates to Complaints IN00443290, IN00443701, and IN00443701 concerning medication administration errors, inadequate pain management, resident abuse, and poor medical record documentation.

The facility failed to ensure proper medication administration as ordered, adequate pain management including assessment and non-pharmacological interventions, implementation of a resident's behavior care plan related to dementia, and accurate medical record documentation for pain medication administration.

Complaint IN00443290 involved medication administration deficiencies cited at F684. Complaint IN00443701 involved deficiencies related to pain management, behavior care, and medical record documentation cited at F697, F744, and F842.

The facility failed to ensure residents received medications as ordered, properly monitored and assessed pain management, implemented behavior care plans for residents with dementia, and accurately documented medical records related to pain medication administration.

This citation relates to Complaints IN00430826, IN00431391, IN00431447 (pressure ulcer care), and IN00430737 (fall prevention).

The facility failed to provide effective pressure ulcer prevention and treatment, resulting in a resident developing a severe sacral wound that led to hospitalization for septic shock. The facility also failed to ensure adequate supervision during mechanical lift transfers, causing a resident to fall and sustain a fracture. Additionally, the facility did not complete timely documentation related to a resident's change in condition.

The investigation was triggered by complaints IN00430737, IN00430826, IN00431391, and IN00431447. Substandard quality of care and immediate jeopardy were identified related to falls and supervision. Specific complaints cited deficiencies at tags F689, F686, and F842.

The facility failed to provide adequate supervision during mechanical lift transfers resulting in a resident fall and fracture, and failed to ensure fall prevention interventions such as call lights within reach. Additionally, the facility failed to maintain timely and complete medical records for a resident with a change in condition.

The inspection relates to Complaints IN00427627, IN00426658, and IN00428128. Issues included medication self-administration, resident discharge procedures, skin care, and nurse staffing postings.

The facility failed to properly assess and document residents' ability to self-administer medications, did not complete required discharge planning and documentation for a resident-initiated discharge, failed to provide appropriate treatment and documentation for a resident's skin condition, and did not maintain up-to-date nurse staffing postings including facility census information.

The visit was complaint-driven based on complaints IN00426658, IN00427627, and IN00428128. Deficiencies related to these complaints were cited at tags F684, F732, and F622.

The facility was found deficient in multiple areas including failure to properly assess residents for self-administration of medications, inadequate documentation and planning for resident-initiated discharge, failure to provide appropriate treatment and documentation for skin conditions, and failure to maintain accurate and current nurse staffing postings.

The facility was found not in compliance with Life Safety Code requirements including issues with fire door latching, fire alarm system maintenance, sprinkler system deficiencies, corridor door latching, and combustible materials stored too close to oxygen equipment. Immediate corrective actions were taken for door latching issues and combustible material removal. Plans of correction and monitoring systems were established.

The facility had multiple deficiencies including failure to develop complete care plans for psychotropic medications, incomplete care plan meetings, inadequate assistance with activities of daily living, insufficient treatment and monitoring of skin conditions and falls, lack of vision services, incomplete pressure ulcer care, inadequate fall prevention measures, failure to provide timely nutritional interventions, improper respiratory care including oxygen and tracheostomy management, failure to prevent injury in residents with dementia, medication management issues including missed and unnecessary medications, and failure to implement infection control precautions for residents on isolation.

Complaint IN00420140 - No deficiencies related to the allegations are cited. Complaint IN00423323 - No deficiencies related to the allegations are cited. Complaint IN00423640 - Federal/State deficiencies related to the allegations are cited at F757.

The facility was found deficient in multiple areas including failure to notify responsible parties of transfers, incomplete care plans for psychotropic medications, incomplete care plan meetings, inadequate assistance with activities of daily living, incomplete treatment and monitoring of skin conditions and falls, failure to ensure residents received necessary vision services, incomplete wound treatment documentation, improper footwear for fall prevention, oxygen and tracheostomy care deficiencies, medication management issues including unnecessary medications and lack of documentation of non-pharmacological interventions, infection control deficiencies related to isolation precautions, and incomplete personnel records including orientation, health screenings, and training.

The investigation was triggered by Complaint IN00423640 concerning medication management issues, including missed doses and improper documentation. The complaint was substantiated based on findings.

The facility failed to ensure appropriate medication management related to missed medications, timing of medications, and lack of indication for Morphine Sulfate use for two residents. Medication administration records and interviews revealed discrepancies and missing documentation.

The investigation was triggered by complaints IN00416460 and IN00417422. Complaint IN00416460 related to food safety deficiencies, and Complaint IN00417422 related to quality of care deficiencies. Both complaints resulted in federal/state deficiencies being cited.

The facility was found deficient in ensuring proper assessment and monitoring of a resident prior to hospital transfer and adherence to hospice orders, as well as failure to monitor and document food temperatures for meals, potentially affecting all residents.

This Federal tag relates to Complaint IN00417422 for the resident assessment and hospice order issue, and Complaint IN00416460 for the food temperature monitoring issue.

The facility failed to ensure a resident was assessed and monitored prior to hospital transfer and did not follow hospice orders for blood draws. Additionally, the facility failed to document food temperatures for multiple meals, potentially affecting 100 residents receiving food from the kitchen.

The complaint IN00412775 alleged failures in notification of changes in condition, emergency care, accident prevention, and nutritional care. The investigation substantiated these issues with multiple residents affected.

The facility failed to notify responsible parties and physicians of significant changes in residents' conditions including medication refusals, weight loss, and decreased dietary and fluid intake. Emergency care was inadequate for a resident with respiratory distress, including failure to call 911. The facility also failed to ensure assistive devices were used to prevent falls and did not maintain adequate nutrition and hydration for residents with significant weight loss and poor intake.

Complaint IN00412775 - Federal/state deficiencies related to the allegations are cited at F580, F684, F689, and F692.

The facility failed to notify responsible parties and physicians of significant changes in residents' conditions, failed to provide appropriate emergency care including timely 911 transport, failed to ensure assistive devices were used to prevent falls, and failed to maintain residents' nutritional and hydration status with proper documentation and provision of supplements.

The inspection was triggered by multiple complaints including IN00404721, IN00405373, IN00405569, IN00411260, and IN00399021, alleging failures in care, medication administration, environment cleanliness, and documentation.

The facility was found deficient in multiple areas including failure to provide adequate assistance with activities of daily living, incomplete incontinence care, failure to provide transportation services as ordered, incomplete skin and wound assessments, inadequate fall prevention interventions, improper PICC line care, failure to administer pain medication as ordered, inappropriate medication management, incomplete meal consumption documentation, and failure to maintain a clean and safe environment.

This visit was for the investigation of complaints IN00399021, IN00404721, IN00405373, IN00405569, IN00407582, and IN00411260. Deficiencies were cited related to multiple complaints except IN00407582 where no deficiencies were found.

The facility was found deficient in multiple areas including failure to provide adequate ADL care, quality of care issues such as missed transportation and skin assessments, pressure ulcer care, fall prevention interventions, PICC line care, pain management, medication administration, resident record completeness, and environmental cleanliness and maintenance.

Complaint IN00395443 was substantiated with federal/state deficiencies cited at F677. Complaints IN00392424 and IN00392575 were not corrected. Complaint IN00392985 was corrected.

The facility failed to ensure dependent residents received assistance with activities of daily living, specifically twice weekly showers or bed baths for one resident. Several complaints were substantiated or not corrected, with deficiencies cited related to ADL care.

Complaint IN00392424 - Not Corrected. Complaint IN00392575 - Not Corrected. Complaint IN00392985 - Corrected. Complaint IN00395443 - Substantiated. Federal/State deficiencies related to the allegations are cited at F677.

The facility had multiple deficiencies including failure to provide adequate ADL care for dependent residents, failure to ensure residents did not receive unnecessary psychotropic medications, and failure to maintain sanitary food preparation and kitchen environment. The facility implemented corrective actions including re-education of staff, cleaning and repair of kitchen equipment, and ongoing monitoring.

The facility was found not in compliance with Life Safety Code requirements, with deficiencies including unsealed penetrations in the boiler room, overdue backflow prevention device testing, ceiling construction issues affecting sprinkler operation, overdue fire extinguisher maintenance, exposed electrical outlets, improper segregation and marking of oxygen cylinders, obstructed egress corridors, and oversized soiled linen and trash receptacles in corridors.

The facility had multiple deficiencies including failure to ensure proper medication self-administration orders, timely notification of hospital transfers, care plan conference invitations, assistance with activities of daily living, monitoring of bruising, range of motion interventions, fall prevention measures, catheter care, pain management, medication administration accuracy, infection control practices, food safety and sanitation, and vaccination education.

Complaint IN00392424 - Substantiated. Federal/State deficiencies related to the allegations are cited at F677, F692, F758, and F921. Complaint IN00392575 - Substantiated. Federal/State deficiencies related to the allegations are cited at F697 and F921. Complaint IN00392985 - Substantiated. Federal/State deficiencies related to the allegations are cited at F689.

The facility was cited for multiple deficiencies including medication self-administration, transfer/discharge notice requirements, care plan participation, ADL assistance, quality of care, range of motion, fall prevention, catheter care, nutrition and hydration, tube feeding management, pain management, unnecessary medications, medication storage, food service, infection control, immunizations, environment cleanliness, pre-admission evaluation, and tuberculosis testing.

Five complaints were investigated. Complaints IN00379319, IN00389260, and IN00390448 were substantiated with deficiencies cited. Complaints IN00380478 and IN00390827 were substantiated but no deficiencies related to the allegations were cited.

The facility was found to have multiple deficiencies including failure to provide care according to professional standards after a resident choked on food and medication administration errors, resulting in a medication error rate of 6.25%. Additionally, a duplicate medication order was found in a resident's record. Several complaints were substantiated with related deficiencies cited.