Dyer Nursing and Rehab: Blood Clot Results Delayed 6 Days - IN
The resident, identified in inspection records only as Resident D, had a medical history that made the delay particularly serious. In addition to a prior stroke, the resident had aphasia, making verbal communication difficult, and hemiparesis, partial paralysis on one side of the body. They needed maximum assistance to bathe and dress, and required fully dependent care for toileting. A quarterly assessment from May 2025 rated them as severely impaired for daily decision making. They could not advocate for themselves in any straightforward way.
On July 29, a nurse documented new onset swelling and pain in the resident's right lower extremity and foot. A nurse practitioner was notified and ordered a Doppler ultrasound, a non-invasive imaging test used to assess blood flow. The paperwork was ready. A technician would arrive within 24 hours.
The technician came the next morning. By 10:30 a.m. on July 30, the Doppler was done. A nurse noted the NP had been made aware the tech was on site and that results would be ready within the hour.
The results were ready at 12:25 p.m.
The report showed a partial blood clot in the superficial femoral vein of the right leg, running from the proximal to distal portion of the vessel, partially blocking blood flow. The clinical term in the report was luminal stenosis. The finding was abnormal. It required a response.
Nobody documented notifying the physician or nurse practitioner that day. Nobody documented any follow-up the next day, or the day after that. Inspection records show no documentation of any communication about the Doppler results between July 30 and August 5, a span of six days.
On August 5, a new order appeared in the resident's chart: Eliquis, a blood thinner, 5 milligrams twice daily by mouth. The physician's order was dated that same day. There is no documentation explaining what prompted the order on August 5 or why it had not been written on July 30.
When federal inspectors interviewed the Director of Nursing on August 11, she confirmed the Doppler had been ordered July 29 and completed July 30. She said she had contacted the company that interpreted the results, and they told her the results had been reported on July 30. She could not determine when those results had been communicated to the physician. She told inspectors she understood there had been a delay in treatment.
The inspection was triggered by a complaint. Inspectors cited the facility for failing to report diagnostic results to a physician in a timely manner, resulting in delayed treatment. The level of harm was assessed as minimal harm or potential for actual harm, one step below the threshold that triggers immediate federal intervention.
What that classification does not capture is what the six days looked like for Resident D. The July 30 nurse's note documented that the swelling was continuing. A partial clot blocking venous blood flow in the leg carries risks that compound over time, including the possibility of the clot extending or, in more serious presentations, breaking loose. The resident had no reliable way to ask why nothing was changing, no way to know that a report existed, and no way to know that no one had called the doctor.
The blood thinner order arrived on August 5. By then, the clot had been documented for 144 hours.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Dyer Nursing and Rehabilitation Center from 2025-08-11 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 3, 2026 · Our methodology
DYER NURSING AND REHABILITATION CENTER in DYER, IN was cited for violations during a health inspection on August 11, 2025.
The resident, identified in inspection records only as Resident D, had a medical history that made the delay particularly serious.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.