Ignite Medical Resort Dyer: Infection Control Gaps - IN
Federal inspectors found the facility's records showed checkmarks indicating bladder scans were performed, but the actual measurements were missing from medical charts for two residents who needed the monitoring for serious urinary conditions.
Resident D, diagnosed with urine retention along with heart failure and chronic kidney disease, received a physician's order on September 24 requiring daily post-void bladder scans for one week. The doctor's office was to be notified of results daily.
The medication administration record showed initials and checkmarks indicating scans were completed from September 25 through 30. But nowhere in the resident's chart — not on the medication record, not in nurses' progress notes, not on bladder scan evaluation forms — was there documentation of how much urine remained in the bladder after each scan.
The Unit Manager told inspectors on November 19 that bladder scans were completed and she had personally e-faxed the physician's office. She said the scans should have been documented on bladder scan evaluation forms and in nurses' progress notes.
The Director of Nursing confirmed there was no documentation of urine amounts found during the scans, except for one entry on September 25 at 7:02 p.m. showing 240 cubic centimeters.
Resident E faced similar documentation gaps. This resident, diagnosed with urinary tract infection, diabetes, Parkinson's disease and dementia, received a physician's order on October 31 for bladder scans every eight hours for three days.
The medication record scheduled scans at 6:00 a.m., 2:00 p.m. and 10:00 p.m. from November 1 through November 3. Staff initialed and checked off four scans as completed — November 1 at 2:00 p.m. and 10:00 p.m., and November 2 at 6:00 a.m. and 2:00 p.m.
Again, the amount of urine found during each scan was nowhere to be found in the resident's medical record.
No nurses' progress notes documented the results. No bladder evaluation forms were completed. The Director of Nursing confirmed on November 20 that documentation of urine amounts was missing.
Bladder scans measure how much urine remains in the bladder after a person attempts to empty it. For residents with conditions like urine retention or urinary tract infections, these measurements help doctors determine if treatments are working and whether interventions like catheterization are needed.
The facility's own bladder scan policy, dated November 2025 and provided to inspectors as current, specifically stated that the amount of urine found during scans would be recorded.
Without proper documentation, physicians cannot track whether residents' urinary conditions are improving or worsening. The missing measurements also prevent medical staff from identifying patterns that might indicate complications or the need for treatment changes.
The inspection found that while staff were performing the ordered procedures, they were essentially rendering them medically useless by failing to record the results that doctors needed to make treatment decisions.
Both residents required the monitoring due to serious underlying conditions. Resident D's urine retention, combined with heart failure and kidney disease, made accurate bladder measurements crucial for managing fluid balance and preventing complications.
Resident E's combination of urinary tract infection and neurological conditions from Parkinson's disease and dementia created additional risks that proper bladder monitoring could help address.
The facility's practice of checking off completed procedures without documenting results meant physicians were operating blind when making decisions about these residents' urinary care. The missing documentation violated both physician orders and the facility's own policies for bladder scan procedures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ignite Medical Resort Dyer LLC from 2025-11-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
IGNITE MEDICAL RESORT DYER LLC in DYER, IN was cited for violations during a health inspection on November 20, 2025.
The doctor's office was to be notified of results daily.
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.