Dyer Nursing and Rehab: Infection Control Failures - IN
The resident had Klebsiella pneumoniae bacteria in her urine, a potentially dangerous organism that required enhanced barrier precautions. Federal inspectors documented the November 24 incident as part of a complaint investigation at Dyer Nursing and Rehabilitation Center.
Seventeen minutes later, inspectors found a second nursing assistant finishing incontinence care in another room. She wore gloves but no gown, despite a door sign indicating both residents required enhanced barrier precautions for multidrug-resistant organisms.
The assistant told inspectors she was "unsure of the facility's EBP policy" and then read the sign on the door explaining the requirements.
Resident E, who received the 4:52 a.m. care, had diabetes and a urinary tract infection along with the Klebsiella pneumoniae bacteria. Her care plan from November 3 specified that enhanced barrier precautions were required, with gowns and gloves mandated for "high contact resident care activities." She needed maximum assistance for toileting and bathing and was occasionally incontinent.
The physician's order was clear: enhanced barrier precautions due to Klebsiella pneumoniae in the urine, with gowns and gloves required for intimate care.
Resident L faced similar risks. The resident had spinal stenosis and a urinary tract infection, requiring maximum assistance for toileting and bed mobility. Staff provided all bathing care, and the resident was frequently incontinent of both bowel and bladder.
A November 12 physician's order specified enhanced barrier precautions related to multidrug-resistant organisms in the urine. Like Resident E, gowns and gloves were required for high-contact care activities.
The nursing assistant caring for Resident L was a new employee still in orientation, according to the facility's RN nurse consultant interviewed on November 25.
Federal guidelines are explicit about enhanced barrier precautions. The facility's own policy, dated March 2024, required the precautions for residents with any multidrug-resistant organisms. The policy specifically covered dressing, bathing, hygiene, and changing briefs.
Both violations occurred during the overnight shift when fewer supervisors are present. The first nursing assistant had completed hand hygiene and gathered supplies but failed to notice the isolation sign until stopped by the observer. The second assistant had already finished providing care without the required gown.
Multidrug-resistant organisms pose serious risks in nursing homes, where residents often have compromised immune systems and share common areas. Klebsiella pneumoniae can cause severe infections including pneumonia, bloodstream infections, and urinary tract infections that resist standard antibiotic treatment.
The facility's infection control failures put vulnerable residents at risk. Both residents requiring enhanced precautions needed maximum assistance with personal care and were frequently or occasionally incontinent, creating multiple daily opportunities for bacterial transmission.
Enhanced barrier precautions exist specifically to prevent the spread of dangerous organisms between residents and staff. When nursing assistants skip required protective equipment, they can carry bacteria from room to room on their clothing and skin.
The inspection found the facility failed to ensure correct personal protective equipment use by staff members when providing care to residents in enhanced barrier precautions and contact isolation. Federal inspectors classified the violations as having minimal harm or potential for actual harm.
One nursing assistant didn't recognize the isolation requirements until after being stopped. The other admitted uncertainty about the facility's policy while standing in a room where she had just provided intimate care without proper protection.
Both residents remained dependent on staff for basic care, creating ongoing infection risks each time protocols are ignored or forgotten.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Dyer Nursing and Rehabilitation Center from 2025-11-25 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
DYER NURSING AND REHABILITATION CENTER in DYER, IN was cited for violations during a health inspection on November 25, 2025.
The resident had Klebsiella pneumoniae bacteria in her urine, a potentially dangerous organism that required enhanced barrier precautions.
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.