Inspection Reports for Dyer Nursing and Rehabilitation Center
601 SHEFFIELD AVE, IN, 46311
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Inspection Report
Follow-Up
Census: 121
Capacity: 161
Deficiencies: 0
May 20, 2025
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on previous Emergency Preparedness and Life Safety Code surveys that exited on 04/29/2025 and 03/17/2025 respectively.
Findings
At this Post Survey Revisit, Dyer Nursing and Rehabilitation Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility was fully sprinklered and had a fire alarm system with hard wired smoke detection in resident rooms, corridors, and spaces open to corridors.
Report Facts
Certified beds: 161
Census: 121
Inspection Report
Follow-Up
Census: 122
Capacity: 161
Deficiencies: 2
Apr 29, 2025
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on the Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey that exited on 03/17/2025.
Findings
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.
Severity Breakdown
SS=F: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure the Emergency Preparedness Communication Plan includes contact information for federal, state, tribal, regional, and local emergency preparedness staff, the State Licensing and Certification Agency, the Office of the State Long-Term Care Ombudsman, and other sources of assistance. | SS=F |
| Failed to maintain automatic sprinkler systems with supervisory signals as required by Life Safety Code, including two sprinkler valves not electrically supervised. | SS=F |
Report Facts
Certified beds: 161
Census: 122
Date of compliance: May 6, 2025
Date of compliance: May 9, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bradley Macklin | Administrator | Signed the report |
| Director of Maintenance | Interviewed regarding deficiencies in emergency preparedness communication plan and sprinkler system |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 155
Deficiencies: 0
Mar 26, 2025
Visit Reason
This visit was for the investigation of multiple nursing home complaints (IN00453758, IN00454225, IN00455534) and a residential complaint (IN00455516), conducted in conjunction with post survey revisits to prior recertification, state licensure, and complaint investigations.
Findings
No deficiencies related to the allegations in complaints IN00453758, IN00454225, IN00455534, and IN00455516 were cited. Previous complaints IN00450533 and IN00451791 were corrected. The facility was found to be in compliance with relevant federal and state regulations.
Complaint Details
Complaints IN00453758, IN00454225, IN00455534, and IN00455516 were investigated with no deficiencies cited. Complaints IN00450533 and IN00451791 were corrected.
Report Facts
Census: 118
Total Capacity: 155
Residential Census: 35
Medicare Census: 16
Medicaid Census: 92
Other Payor Census: 10
Inspection Report
Re-Inspection
Census: 118
Capacity: 155
Deficiencies: 0
Mar 26, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey and the PSR to the Investigation of Complaints IN00450533 and IN00451791 completed on 2/11/25. It also included PSRs to other complaint investigations and the State Residential Licensure Survey.
Findings
Dyer Nursing and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey and the PSR to the Investigation of Complaints IN00450533 and IN00451791. Several complaints were corrected or had no deficiencies related to the allegations.
Complaint Details
Complaint IN00450533 and IN00451791 were corrected. Complaints IN00453758, IN00454225, IN00455516, and IN00455534 had no deficiencies related to the allegations cited.
Report Facts
Census SNF/NF: 118
Total Capacity: 155
Residential Census: 35
Census Payor Type Medicare: 16
Census Payor Type Medicaid: 92
Census Payor Type Other: 10
Inspection Report
Census: 120
Capacity: 161
Deficiencies: 14
Mar 17, 2025
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal and state regulations.
Findings
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.
Severity Breakdown
SS=F: 10
SS=E: 4
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to ensure emergency preparedness policies include arrangements with other LTC facilities to receive patients during limitations or cessation of operations. | SS=F |
| Emergency Preparedness Communication Plan lacked required contact information for federal, state, tribal, regional, and local emergency preparedness staff and agencies. | SS=F |
| Failed to develop and maintain an emergency preparedness training and testing program based on the emergency plan, risk assessment, policies, and communications plan. | SS=F |
| Failed to conduct annual training for the Emergency Preparedness Program (EPP). | SS=F |
| Exit sign in West Memory Care Unit Dining Room was not continuously illuminated. | SS=E |
| Failed to provide an approved method for returning cooking appliances to their approved design location under the kitchen hood extinguishing system. | SS=E |
| Failed to provide a complete written policy for fire alarm system out-of-service events lasting 4 hours or more in a 24-hour period. | SS=F |
| Failed to maintain automatic sprinkler systems with required supervisory signals and electrical supervision of sprinkler valves. | SS=F |
| Failed to ensure automatic sprinkler piping systems were examined for internal obstructions as required every 5 years. | SS=F |
| Failed to provide a complete written policy for automatic sprinkler system out-of-service events lasting 10 hours or more in a 24-hour period. | SS=F |
| Failed to ensure fuel fired water heater had a current inspection certificate to ensure safe operating condition. | SS=F |
| Failed to provide ground fault circuit interrupter (GFCI) protection for an electric receptacle in resident room 129 bathroom and for a sink location in the MDS office. | SS=E |
| Failed to ensure flexible cords were not used as substitutes for fixed wiring in multiple locations including the theater, North Memory Care Unit nurses' station, and wound care office. | SS=E |
| Used a multiplug power strip in resident room 125 that lacked UL 1363 label for patient care vicinity equipment. | — |
Report Facts
Certified beds: 161
Census: 120
Deficiencies cited: 14
Sprinkler systems: 5
Resident rooms: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bradley Macklin | Administrator | Named in relation to findings and exit conference |
| Director of Maintenance | Interviewed and involved in multiple findings related to emergency preparedness, fire safety, and electrical issues | |
| Senior Administrator | Participated in exit conference and interviews regarding findings |
Inspection Report
Recertification
Census: 155
Deficiencies: 23
Feb 11, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaints IN00450533, IN00451227, and IN00451791.
Findings
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.
Complaint Details
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.
Severity Breakdown
SS=E: 5
SS=D: 3
Deficiencies (23)
| Description | Severity |
|---|---|
| Resident Rights/Exercise of Rights - facility failed to ensure resident's dignity related to wearing a hospital gown while in bed during the day. | — |
| Resident Self-Admin Meds - facility failed to ensure residents were assessed and had physician's orders to self-administer medications and oxygen therapy. | — |
| Coordination of PASARR and Assessments - facility failed to ensure PASARR level 2 was completed when a new mental health diagnosis was added. | — |
| Develop/Implement Comprehensive Care Plan - failed to develop individualized care plan for bilateral amputee. | — |
| Care Plan Timing and Revision - failed to ensure residents received care conferences and were informed of new medications and lab results. | — |
| ADL Care Provided for Dependent Residents - failed to provide timely assistance with meals, showers, oral care, nail care, and repositioning for multiple residents. | — |
| Quality of Care - failed to ensure insulin was signed out as ordered, treatments for skin conditions were ordered and monitored, edema addressed, and lung sounds assessed after change in condition. | SS=E |
| Increase/Prevent Decrease in ROM/Mobility - failed to ensure physician-ordered splint was in place for resident with limited range of motion. | — |
| Free of Accident Hazards/Supervision/Devices - failed to supervise residents in memory care during meals. | SS=E |
| Nutrition/Hydration Status Maintenance - failed to assist residents with meals and document nutritional supplement consumption for residents with weight loss history. | — |
| Tube Feeding Mgmt/Restore Eating Skills - failed to check gastrostomy tube placement prior to medication administration, failed to instill medications and flushes via gravity, and failed to document gastrostomy tube care. | — |
| Respiratory/Tracheostomy Care and Suctioning - failed to ensure oxygen was administered at correct flow rate for residents on oxygen therapy. | — |
| Free of Medication Error Rate of 5% or More - medication errors observed including incorrect insulin dose, administration of discontinued medication, and incorrect antibiotic dilution. | SS=D |
| Label/Store Drugs and Biologicals - failed to ensure controlled substances were double locked and multi-use vials were dated after opening. | SS=D |
| Routine/Emergency Dental Services in SNFs - failed to ensure resident received routine dental services. | SS=D |
| Infection Prevention & Control - failed to disinfect multi-use equipment, perform hand hygiene after glove removal, don PPE for enhanced barrier precautions, contain soiled linen, and properly store personal care equipment. | SS=E |
| Residents' Rights - Deficiency - failed to provide written discharge instructions for continuity of care after discharge. | — |
| Administration and Management - Noncompliance - failed to conduct at least 1 fire drill quarterly on each shift. | — |
| Evaluation - Noncompliance - failed to complete current smoking assessment for resident who smoked on facility property. | — |
| Evaluation - Deficiency - failed to ensure service plans were accurate and reflective of resident's current status related to smoking, insulin dependent diabetes, self-administration of medication, infections, and psychotropic medications. | — |
| Health Services - Deficiency - failed to ensure insulin was signed out as administered as ordered by physician. | — |
| Pharmaceutical Services - Noncompliance - failed to obtain antibiotic timely for resident with urinary tract infection. | — |
| Clinical Records - Noncompliance - failed to ensure resident's record was complete related to documentation and assessment after emergency room visit. | — |
Report Facts
Census: 155
Medication error rate: 11.7
Weight loss: 10
Weight loss: 11.2
Insulin dose: 8
Insulin dose: 10
Medication administration omissions: 6
Medication administration omissions: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bradley Macklin | Administrator | Signed report cover page |
| LPN 1 | Named in medication administration and resident assessment findings | |
| RN 3 | Named in medication administration and infection control findings | |
| Assistant Director of Nursing (ADON) 1 | Named in oxygen therapy and resident assessment findings | |
| Nurse Consultant 1 | Provided policies and interviewed regarding medication and infection control |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 30, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of complaints IN00443290 and IN00443701 completed on September 26, 2024.
Findings
Dyer Nursing and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
The visit was related to complaint investigations IN00443290 and IN00443701, with the facility found in compliance upon paper review.
Inspection Report
Complaint Investigation
Census: 122
Capacity: 158
Deficiencies: 4
Sep 26, 2024
Visit Reason
This visit was for the investigation of complaints IN00443290 and IN00443701 regarding medication administration and resident care concerns.
Findings
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.
Complaint Details
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.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure medications were administered as ordered for 2 of 15 residents. | SS=D |
| Failure to monitor and assess pain, evaluate medication effectiveness, and attempt non-pharmacological interventions for 1 of 2 residents. | SS=D |
| Failure to implement behavior plan of care for a resident with dementia exhibiting aggressive behaviors. | SS=D |
| Failure to ensure medical records were thoroughly and accurately documented related to pain medication administration. | SS=D |
Report Facts
Residents reviewed for quality of care: 15
Residents reviewed for injury of unknown origin: 2
Residents reviewed for abuse: 2
Census SNF/NF beds: 122
Census Residential beds: 36
Total licensed capacity: 158
Medicare census: 7
Medicaid census: 92
Other payor census: 23
PRN Norco administrations: 11
Days medication administered: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Maurice | Administrator | Signed report and provided interview regarding resident behavior incident |
| LPN 1 | Nurse involved in resident behavior incident, terminated for failing to deescalate situation | |
| Director of Nursing | Director of Nursing (DON) | Provided interviews regarding medication administration and pain management |
| Nurse Consultant | Provided pharmacy audit reports and acknowledged medication documentation issues | |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed about medication ordering procedures |
| CNA 1 | Certified Nursing Assistant | Provided interview about resident pain complaints |
| CNA 2 | Certified Nursing Assistant | Provided telephone interview about resident behavior incident |
| CNA 3 | Certified Nursing Assistant | Witnessed resident behavior incident but unavailable for interview |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 152
Deficiencies: 0
Jul 10, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00437294 at Dyer Nursing and Rehabilitation Center.
Findings
No deficiencies related to the allegations in Complaint IN00437294 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00437294 found no deficiencies related to the allegations; the complaint was not substantiated.
Report Facts
Census SNF/NF: 113
Census Residential: 39
Total Capacity: 152
Census Payor Type Medicare: 11
Census Payor Type Medicaid: 84
Census Payor Type Other: 18
Inspection Report
Re-Inspection
Census: 112
Capacity: 150
Deficiencies: 0
May 1, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00430737, IN00430826, IN00431391, and IN00431447 completed on April 5, 2024.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaints. All complaints investigated were corrected.
Complaint Details
This visit was related to the investigation of complaints IN00430737, IN00430826, IN00431391, and IN00431447. All complaints were corrected.
Report Facts
Census SNF/NF: 112
Census Residential: 38
Total Capacity: 150
Census Medicare: 14
Census Medicaid: 83
Census Other Payor: 15
Total Census Payor: 112
Inspection Report
Complaint Investigation
Census: 146
Capacity: 146
Deficiencies: 3
Apr 1, 2024
Visit Reason
This visit was for the investigation of complaints IN00430737, IN00430826, IN00431391, and IN00431447, resulting in a Partially Extended Survey with findings of Substandard Quality of Care and Immediate Jeopardy.
Findings
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.
Complaint Details
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.
Severity Breakdown
SS=G: 2
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure adequate supervision during sit-to-stand mechanical lift transfer resulting in resident fall and fracture. | SS=G |
| Failed to ensure fall prevention intervention with call light within reach for residents. | SS=G |
| Failed to maintain resident medical records complete, accurate, and timely, including late entries for change in condition. | SS=D |
Report Facts
Survey dates: April 1, 3, 4, and 5, 2023
Census Bed Type - SNF/NF: 108
Census Bed Type - Residential: 38
Total Census: 146
Medicare Census: 11
Medicaid Census: 82
Other Payor Census: 15
Fall on 2/3/24 hematoma size: 2
Pain rating: 7
Blood pressure: 96
Pulse: 108
Respirations: 16
Oxygen saturation: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Maurice | Administrator | Signed report and provided statements related to investigation |
| Past Employee CNA 4 | Named in fall incident for transferring resident without assistance | |
| LPN 1 | Licensed Practical Nurse | Authored late progress notes and change of condition assessments |
Inspection Report
Re-Inspection
Census: 113
Capacity: 161
Deficiencies: 0
Mar 12, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 01/29/24 was performed to verify compliance with Life Safety Code requirements.
Findings
At this Life Safety Code PSR, Dyer Nursing and Rehabilitation Center was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered with a fire alarm system and hard-wired smoke detection throughout.
Report Facts
Facility capacity: 161
Census: 113
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 12, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of complaints IN00426658, IN00427627, and IN00428128 completed on February 20, 2024.
Findings
Dyer Nursing and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
The visit was complaint-related, reviewing three complaint investigations (IN00426658, IN00427627, IN00428128). The facility was found in compliance with no deficiencies cited.
Inspection Report
Life Safety
Census: 115
Capacity: 161
Deficiencies: 0
Feb 27, 2024
Visit Reason
A Life Safety Code Preoccupancy Survey was conducted by the Indiana Department of Health to assess compliance with 42 CFR 483.90(a) related to building modifications and fire safety systems.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements and life safety code standards. The building is Type V (111) construction, fully sprinklered, with a fire alarm system including hard-wired smoke detection in resident rooms, corridors, and common areas.
Report Facts
Resident census: 115
Total capacity: 161
Number of residents accommodated in new locked wing: 20
Inspection Report
Complaint Investigation
Census: 147
Capacity: 147
Deficiencies: 4
Feb 19, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00426658, IN00427627, and IN00428128 regarding various deficiencies at the facility.
Findings
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.
Complaint Details
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.
Severity Breakdown
SS=D: 3
SS=C: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to determine self-administration of medications was appropriate for residents, with medications left in rooms without proper assessment or care plans for 2 residents. | SS=D |
| Failure to ensure requirements for resident-initiated discharge were completed, including lack of documentation of intent, discharge planning, discussion with resident or responsible party, and discharge summary for 1 resident. | SS=D |
| Failure to provide treatment and care in accordance with professional standards related to assessment, treatment, and documentation of a skin condition for 1 resident. | SS=D |
| Failure to ensure posted nurse staffing information was up-to-date and included facility census, affecting all residents. | SS=C |
Report Facts
Census Bed Type - SNF/NF: 110
Census Bed Type - Residential: 37
Total Capacity: 147
Census Payor Type - Medicare: 15
Census Payor Type - Medicaid: 80
Census Payor Type - Other: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Maurice | Administrator | Signed the report and provided current Self-Administration of Medication Policy |
Inspection Report
Life Safety
Census: 116
Capacity: 161
Deficiencies: 5
Jan 29, 2024
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and the 2012 edition of the NFPA 101 Life Safety Code.
Findings
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.
Severity Breakdown
SS=E: 2
SS=F: 2
SS=D: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Fire doors separating health care from assisted living did not latch, failing to limit smoke spread. | SS=E |
| Fire alarm system was not maintained properly; door holders were not repaired and fire alarm was disabled in Memory Care unit. | SS=F |
| Automatic sprinkler system deficiencies including missing supervisory switch wiring, missing signage, and lack of records for antifreeze loop maintenance. | SS=F |
| Resident room corridor door did not latch properly, failing to resist passage of smoke. | SS=D |
| Combustible materials stored within 5 feet of oxygen storage/transfilling area, violating separation requirements. | SS=E |
Report Facts
Certified beds: 161
Census: 116
Resident rooms with door holder issues: 14
Resident room corridor doors inspected monthly: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Maurice | Administrator | Signed report and involved in exit conference |
| Maintenance Director | Interviewed regarding fire door latching, fire alarm system, sprinkler system, and oxygen storage deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 23, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey and the Investigation of Complaint IN00423640 completed on December 20, 2023.
Findings
Dyer Nursing and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Recertification and State Licensure Survey and complaint investigation.
Complaint Details
Investigation of Complaint IN00423640 completed on December 20, 2023; found to be in compliance.
Inspection Report
Recertification
Census: 35
Deficiencies: 13
Dec 20, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaints IN00420140, IN00423323, and IN00423640. This visit included a State Residential Licensure Survey.
Findings
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.
Complaint Details
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.
Deficiencies (13)
| Description |
|---|
| Failed to notify resident's Responsible Party in writing related to a hospital transfer for 1 of 2 residents reviewed. |
| Failed to initiate Care Plans related to psychotropic medications for 1 of 26 residents reviewed. |
| Failed to ensure care plan meetings were completed quarterly and included resident, responsible party, and interdisciplinary team for 2 of 3 residents reviewed. |
| Failed to ensure dependent residents received assistance with nail care and removal of facial hair for 3 of 9 residents reviewed. |
| Failed to ensure treatments were obtained for non-pressure ulcers and bruises and sutures were assessed and monitored for 3 of 3 residents reviewed for skin conditions and falls. |
| Failed to ensure a resident with a history of falls was wearing proper footwear to prevent falls and injury. |
| Failed to ensure Registered Dietitian's recommendations were acted upon timely for a resident with weight loss. |
| Failed to ensure oxygen was on and set at correct flow rate and tracheostomy care was completed as ordered for 4 residents reviewed. |
| Failed to ensure medications were managed appropriately related to missed medications, timing, and no indication for Morphine Sulfate use for 2 residents. |
| Failed to ensure non-pharmacological interventions were attempted prior to administration of anti-anxiety medication and documentation on MAR for 1 resident. |
| Failed to ensure infection control guidelines were implemented related to isolation precautions for 1 resident on antibiotic therapy. |
| Failed to ensure newly hired employees received job specific orientation, physical exam, TB screen, and annual resident rights and dementia training for multiple employees. |
| Failed to ensure health screens were signed by a licensed nurse for 2 employee files reviewed. |
Report Facts
Survey dates: December 13, 14, 15, 18, 19, and 20, 2023
Census: 35
Medication doses: 11
Weight loss: 5
Oxygen flow rate: 2
Oxygen flow rate: 3
Oxygen flow rate: 4
Oxygen flow rate: 9
Lorazepam syringes: 16
Morphine syringes: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Assistant 1 | Lacked documentation of physical exam, TB screen, and job specific orientation | |
| Resident Assistant 2 | Lacked documentation of physical exam, TB screen, and job specific orientation | |
| Activity Aide 1 | Lacked documentation of physical exam | |
| LPN 2 | Licensed Practical Nurse | Lacked documentation of annual TB screen, resident rights and dementia training |
| Housekeeper 1 | Lacked documentation of annual resident rights and dementia training | |
| QMA 1 | Qualified Medication Aide | Lacked documentation of annual dementia training and TB screen |
| CNA 1 | Certified Nursing Assistant | Lacked documentation of annual resident rights and dementia training |
| Dietary Aide 2 | Lacked documentation of annual dementia training | |
| CNA 2 | Certified Nursing Assistant | Lacked documentation of annual dementia training |
| QMA 2 | Qualified Medication Aide | Lacked documentation of annual dementia training |
| LPN 3 | Licensed Practical Nurse | Lacked documentation of annual resident rights and dementia training |
| LPN 4 | Licensed Practical Nurse | Lacked signed health screen |
| Dietary Aide 3 | Lacked signed health screen |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 138
Deficiencies: 2
Sep 21, 2023
Visit Reason
This visit was conducted for the investigation of two complaints, IN00416460 and IN00417422, related to quality of care and food safety at the facility.
Findings
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.
Complaint Details
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.
Severity Breakdown
SS=D: 1
SS=F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure a resident was assessed and monitored prior to hospital transfer and hospice orders were followed as written. | SS=D |
| Failed to ensure food temperatures were monitored and documented for each meal. | SS=F |
Report Facts
Census Bed Type - SNF: 10
Census Bed Type - SNF/NF: 90
Census Bed Type - Residential: 38
Total Licensed Capacity: 138
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 73
Census Payor Type - Other: 17
Total Census: 100
Food temperature documentation missing dates: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Suzanne Maurice | Administrator | Signed the report and interviewed regarding documentation requirements |
| Nurse Consultant 1 | Interviewed regarding lab orders and discontinuation | |
| Dietary Food Manager | Interviewed regarding food temperature monitoring and documentation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 21, 2023
Visit Reason
Paper compliance review to the Investigation of Complaints IN00416460 and IN00417422 completed on September 21, 2023.
Findings
Dyer Nursing and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
Investigation of Complaints IN00416460 and IN00417422; paper compliance review completed and found in compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 31, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of complaint IN00412775 completed on July 26, 2023.
Findings
Dyer Nursing and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
Complaint investigation IN00412775 was reviewed and found to be in compliance; no deficiencies were cited.
Inspection Report
Complaint Investigation
Census: 112
Capacity: 151
Deficiencies: 4
Jul 26, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00412775 related to federal/state deficiencies cited at F580, F684, F689, and F692.
Findings
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.
Complaint Details
Complaint IN00412775 - Federal/state deficiencies related to the allegations are cited at F580, F684, F689, and F692.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to notify resident's Responsible Party and Physician of change in condition related to medication refusals, decreased dietary and fluid intake, and weight changes for 2 of 4 residents reviewed. | SS=D |
| Failed to ensure appropriate emergency care was provided, including failure to call 911 for emergency transport and incomplete assessments prior to transfer for 1 of 3 residents reviewed. | SS=D |
| Failed to ensure assistive devices were utilized as documented to prevent injury from falls for 1 of 3 residents reviewed. | SS=D |
| Failed to ensure residents maintained acceptable nutritional and hydration status related to decreased food and fluid consumption, significant weight loss, weight discrepancies, missing weights, undocumented supplement intake, and incomplete assessments for residents with decreased intake. | SS=D |
Report Facts
Census SNF/NF beds: 112
Census Residential beds: 39
Total Capacity: 151
Medicare Census: 13
Medicaid Census: 85
Other Payor Census: 14
Total Census: 112
Weight loss percentage: 15.7
Weight loss percentage: 11.8
Audit frequency: 10
Audit frequency: 5
Audit duration: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Trina Dean | Regional VP of Clinical | Signed the report |
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 24, 2023
Visit Reason
Paper compliance review to the Investigation of Complaints IN00399021, IN00404721, IN00405373, IN00405569, and IN00411260 plus unrelated deficiency completed on June 28, 2023.
Findings
Dyer Nursing and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the complaint investigation.
Complaint Details
Paper compliance review related to multiple complaint investigations as listed; compliance was found.
Inspection Report
Complaint Investigation
Census: 120
Capacity: 120
Deficiencies: 9
Jun 26, 2023
Visit Reason
Investigation of multiple complaints alleging deficiencies in care and facility conditions at Dyer Nursing and Rehabilitation Center.
Findings
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 Details
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.
Severity Breakdown
SS=D: 8
SS=E: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to ensure dependent residents received help with ADLs related to showers and timely incontinence care. | SS=D |
| Failure to ensure transportation services were provided for physician appointments, weekly skin assessments completed, and follow-up assessments after falls. | SS=D |
| Failure to ensure pressure areas were assessed and monitored related to a blistered heel area. | SS=D |
| Failure to ensure fall interventions were in place for a resident with history of falls and fracture related to floor mattress and bolsters. | SS=D |
| Failure to ensure PICC line bandages were changed weekly and physician orders for PICC care were present. | SS=D |
| Failure to ensure pain medication was administered as ordered for a resident with fractures. | SS=D |
| Failure to manage medications appropriately related to insulin, antibiotics, and antihypertensive medications. | SS=D |
| Failure to maintain complete clinical records related to meal consumption documentation. | SS=D |
| Failure to maintain a safe, functional, sanitary, and comfortable environment including urine odors, dirty floors, marred walls, door frames, and broken closet doors. | SS=E |
Report Facts
Census: 120
Total Capacity: 120
Deficiencies cited: 9
Survey dates: 2023-06-26 to 2023-06-28
Inspection Report
Follow-Up
Census: 125
Capacity: 161
Deficiencies: 0
Feb 17, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 12/28/22 was performed to verify compliance with prior deficiencies and regulatory requirements.
Findings
At this PSR, Dyer Nursing and Rehabilitation Center was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered with a fire alarm system and hard wired smoke detection throughout.
Report Facts
Facility capacity: 161
Census: 125
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 30, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00395443 completed on January 6, 2023.
Findings
Dyer Nursing and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the complaint investigation.
Complaint Details
Investigation of Complaint IN00395443 completed on January 6, 2023; facility found in compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 30, 2023
Visit Reason
Paper compliance review to the Post Survey Revisit (PSR) related to the Recertification and State Licensure Survey and complaint investigations IN00392424 and IN00392575 completed on January 6, 2023.
Findings
Dyer Nursing and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the PSRs for the Recertification and State Licensure Survey and complaint investigation.
Complaint Details
The visit included a review of complaint investigations IN00392424 and IN00392575.
Inspection Report
Complaint Investigation
Census: 112
Capacity: 147
Deficiencies: 1
Jan 5, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00395443 and in conjunction with a Post Survey Revisit to the Recertification and State Licensure Survey and investigations of other complaints.
Findings
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 Details
Complaint IN00395443 was substantiated with federal/state deficiencies cited at F677. Complaints IN00392424 and IN00392575 were not corrected. Complaint IN00392985 was corrected.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure dependent residents received help with Activities of Daily Living related to twice a week showers/bed baths for 1 of 3 residents reviewed. | SS=D |
Report Facts
Census SNF/NF: 112
Census Residential: 35
Total Capacity: 147
Medicare Census: 14
Medicaid Census: 76
Other Payor Census: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natalie Porcaro | Administrator | Named as Laboratory Director's or Provider/Supplier Representative's Signature |
| Director of Nursing | Interviewed regarding lack of documentation for twice weekly bed baths for Resident B |
Inspection Report
Re-Inspection
Census: 35
Capacity: 147
Deficiencies: 4
Jan 5, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey and the Investigation of Complaints IN00392424, IN00392575, IN00392985 completed on 2022-11-22, and the Investigation of Complaint IN00395443.
Findings
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.
Complaint Details
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.
Severity Breakdown
SS=D: 2
SS=E: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure dependent residents received help with Activities of Daily Living (ADLs) related to twice a week showers/bed baths for 1 of 3 residents reviewed. | SS=D |
| Failed to ensure residents did not receive unnecessary psychotropic medications without adequate indications for use for 1 of 3 residents reviewed. | SS=D |
| Failed to serve and prepare food under sanitary conditions related to dirty food equipment, steam tables, wire racks, and standing mixer in the kitchen. | SS=E |
| Failed to ensure the kitchen area was clean and in good repair related to dirty floors, dirty trash cans, lime build up, food build up on floors and baseboards, and food spillage on pipes. | SS=E |
Report Facts
Census Bed Type - SNF/NF: 112
Census Bed Type - Residential: 35
Total Capacity: 147
Census Payor Type - Medicare: 14
Census Payor Type - Medicaid: 76
Census Payor Type - Other: 22
Total Census Payor: 112
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natalie Porcaro | Administrator | Signed the report and mentioned in interview regarding findings |
| Director of Nursing | Interviewed regarding ADL care and psychotropic medication findings | |
| Assistant Dietary Food Manager | Interviewed regarding kitchen sanitation findings | |
| Administrator | Interviewed regarding kitchen sanitation and staffing |
Inspection Report
Life Safety
Census: 115
Capacity: 161
Deficiencies: 8
Dec 28, 2022
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and the 2012 edition of NFPA 101.
Findings
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.
Severity Breakdown
SS=E: 4
SS=F: 2
SS=D: 1
SS=B: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Unsealed 1-inch gap around a pipe in the ceiling of the boiler equipment room allowing smoke to pass. | SS=E |
| Backflow prevention device in sprinkler system was not tested annually as required. | SS=F |
| Ceiling construction in lobby corridor had a six foot opening, potentially delaying sprinkler activation. | SS=F |
| One portable fire extinguisher was overdue for maintenance by more than one year. | SS=D |
| Electrical outlet in Main Lobby Hall attic was not enclosed and had exposed metal terminals. | SS=B |
| Seven oxygen cylinders were mixed full and empty and not marked or segregated properly. | SS=E |
| Rehabilitation corridor was obstructed by four resident beds and a service cart with boxes. | SS=E |
| Two soiled linen receptacles in corridor exceeded 32 gallons capacity within a 64 square foot area. | SS=E |
Report Facts
Facility capacity: 161
Census: 115
Deficiencies cited: 8
Residents affected: 20
Residents affected: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natalie Porcaro | Administrator | Named in relation to exit conference and report signature |
Inspection Report
Annual Inspection
Census: 117
Capacity: 154
Deficiencies: 20
Nov 22, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey and the Investigation of Complaints IN00392424, IN00392575, and IN00392985.
Findings
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.
Complaint Details
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.
Severity Breakdown
SS=D: 15
SS=E: 3
: 2
SS=B: 1
Deficiencies (20)
| Description | Severity |
|---|---|
| Failed to ensure residents had Physician's Orders and assessments for self-administration of medications. | SS=D |
| Failed to notify residents or their representatives in writing before transfer or discharge for 5 of 6 residents reviewed. | SS=B |
| Failed to ensure residents were invited to their care plan conferences for 2 of 2 residents reviewed. | SS=D |
| Failed to ensure dependent residents received help with ADLs including repositioning, hair washing, and showers for 2 of 9 residents reviewed. | SS=D |
| Failed to ensure areas of bruising were assessed and monitored for 1 of 4 residents reviewed for skin conditions. | SS=D |
| Failed to ensure splints were applied as ordered and range of motion was completed for 3 of 3 residents reviewed for limited range of motion. | SS=D |
| Failed to ensure fall interventions were in place for residents with a history of falls related to floor mattress and non-slip socks for 3 of 4 residents reviewed. | SS=D |
| Failed to ensure residents with urinary catheters received catheter care as ordered for 2 of 2 residents reviewed. | SS=D |
| Failed to ensure gastrostomy tube placement was checked prior to medication administration and water flushes were instilled via gravity for 1 of 1 resident. | SS=D |
| Failed to ensure residents did not receive unnecessary psychotropic medications without adequate indications and prn anti-anxiety medications were only administered after non-pharmacological interventions for 2 of 5 residents reviewed. | SS=D |
| Failed to ensure medication carts were locked when out of view on 1 of 3 units. | SS=D |
| Failed to provide a resident with a nourishing, palatable, well-balanced diet and failed to provide special dietary needs for 1 of 3 residents reviewed for nutritional services. | SS=D |
| Failed to serve and prepare food under sanitary conditions related to dirty food equipment, steam tables, wire racks, standing fans, and standing mixer in 1 of 1 kitchens observed. | SS=E |
| Failed to provide a safe, functional, sanitary, and comfortable environment related to dirty floors, marred doors, lime build up, dirty heating unit covers, dirty baseboards, food build up on baseboards, lime build up on pipes, dirty floor tile, and dirty transportation carts on 3 of 4 units and kitchen. | SS=E |
| Failed to complete a Pre-Admission Evaluation for 1 of 7 residents reviewed. | — |
| Failed to ensure a medication self-administration evaluation was completed for 1 of 7 residents reviewed. | — |
| Failed to serve and prepare food under sanitary conditions related to dirty food equipment, steam tables, wire racks, standing fans, and standing mixer in 1 of 1 kitchens observed. | — |
| Failed to ensure residents and/or responsible parties were offered influenza and pneumococcal immunizations and provided education on benefits and side effects for 2 of 5 residents reviewed. | SS=D |
| Failed to ensure infection control guidelines were implemented including hand hygiene, proper PPE use, lancet disposal, mask wearing, wash basin storage, and equipment disinfection for multiple residents and staff. | SS=E |
| Failed to ensure residents had a documented Mantoux test prior to admission and yearly for 2 of 7 residents reviewed. | SS=D |
Report Facts
Census: 117
Total Capacity: 154
Deficiencies cited: 21
Survey dates: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natalie Porcaro | Administrator | Signed the report on 12/14/2022 |
| RN 1 | Named in findings related to medication cart locking and lancet disposal | |
| LPN 1 | Named in findings related to floor mattress placement and mask wearing | |
| LPN 2 | Named in findings related to gastrostomy tube medication administration | |
| Agency CNA 1 | Named in findings related to PPE use and mask wearing | |
| Nurse Consultant | Interviewed multiple times regarding various findings | |
| Dietary Manager | Interviewed regarding kitchen sanitation and food temperatures | |
| Nurse Practitioner | Observed and interviewed regarding infection control practices |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 21, 2022
Visit Reason
The visit was a paper compliance review related to the investigation of complaints IN00379319, IN00389260, and IN00390448 completed on September 29, 2022.
Findings
Dyer Nursing and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
The visit was related to complaint investigations IN00379319, IN00389260, and IN00390448, and the facility was found to be in compliance.
Inspection Report
Complaint Investigation
Census: 119
Capacity: 157
Deficiencies: 3
Sep 29, 2022
Visit Reason
This visit was for the investigation of five complaints (IN00379319, IN00380478, IN00389260, IN00390448, and IN00390827) at Dyer Nursing and Rehabilitation Center.
Findings
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.
Complaint Details
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.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure treatments and care were provided in accordance with professional standards, including lack of interventions and assessments after a resident choked on food and administering discontinued medication. | SS=D |
| Medication error rate exceeded 5%, with 2 errors observed during 32 medication administration opportunities. | SS=D |
| Resident records contained duplicate medication orders leading to inaccurate documentation. | SS=D |
Report Facts
Census SNF/NF: 119
Census Residential: 38
Total Capacity: 157
Medication error rate: 6.25
Medication administration opportunities: 32
Medication errors observed: 2
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