Ignite Medical Resort Dyer: Record Safety Failures - IN
The medication was midodrine, prescribed to treat low blood pressure. The physician's order was explicit: do not give it if the systolic pressure exceeds 90. Nurses gave it anyway, at 8 a.m. and 5 p.m., day after day, from October through mid-November, without recording a blood pressure check beforehand on multiple occasions. When blood pressure was recorded, it was above 90 on nearly every documented administration across both time slots for the entire month of November.
The director of nursing and a nurse consultant both acknowledged to inspectors on November 19 that the medication had been administered with a systolic pressure over 90.
That same resident had come back from a hospital transfer in early October. Physician orders dated October 4 included metoprolol succinate, a heart medication, and empagliflozin, a diabetes drug. Neither order was entered into the system until October 6, and the heart medication wasn't given until October 7, the diabetes medication not until October 8. There was no documentation that the resident or physician had been told about the delay. The director of nursing said the missed orders were caught during an internal audit on October 6.
A separate resident had missed doses of an unspecified medication on September 20, 22, and 23. The pharmacy records showed the drug was available in the emergency dispensing kit during both September and October. Nobody documented why it wasn't given. Nobody notified the physician. The director of nursing told inspectors he hadn't been notified the medications were unavailable and wasn't certain whether staff had checked the emergency kit at all. The facility had switched pharmacies on November 1, he said, because of ongoing delivery problems with the prior vendor.
The inspection was completed November 20, 2025. CMS rated the harm level as minimal or potential for actual harm.
The resident who went days without a heart medication and weeks receiving a drug under the wrong conditions was never, according to the inspection record, told any of it had happened.
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: August 4, 2026 · Our methodology
IGNITE MEDICAL RESORT DYER LLC in DYER, IN was cited for violations during a health inspection on November 20, 2025.
The medication was midodrine, prescribed to treat low blood pressure.
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.