Dyer Nursing and Rehab: Pharmacy Service Failures - IN
The aide walked back to the door, read the isolation sign she had ignored, and then put on the protective gear.
Seventeen minutes later at Dyer Nursing and Rehabilitation Center, inspectors found a second nursing assistant who had just finished changing another resident's soiled brief. She wore gloves but no gown, despite a door sign indicating both residents in the room required enhanced barrier precautions.
When questioned, the second aide said she was "unsure of the facility's EBP policy" and then read the sign on the door.
Federal inspectors documented the November 24 incidents during a complaint investigation at the facility. Both residents had multidrug-resistant organisms in their urine — dangerous bacteria that don't respond to standard antibiotics and can spread rapidly in nursing homes.
Resident E, whose care was interrupted by the inspector, had been diagnosed with Klebsiella pneumoniae bacteria along with diabetes and a urinary tract infection. Her care plan, dated November 3, specifically required enhanced barrier precautions due to the Klebsiella infection. A physician's order from the same date mandated gowns and gloves for "high contact resident care activities."
The resident required maximum assistance for toileting and bathing and was occasionally incontinent. The nursing assistant had completed hand hygiene and put on gloves but was preparing to provide intimate care without the required gown until the inspector intervened.
Resident L, in the second incident, also had a urinary tract infection with multidrug-resistant organisms. A physician's order dated November 12 required enhanced barrier precautions with gown and gloves for high-contact care. The resident needed maximum assistance for toileting and bed mobility, was dependent on staff for bathing, and was frequently incontinent of bowel and bladder.
The nursing assistant had just completed incontinence care and placed the soiled brief in the waste basket — all without wearing the required gown.
During an interview the following day, a registered nurse consultant told inspectors that the second nursing assistant was a new employee still in orientation.
The facility's enhanced barrier precautions policy, dated March 2024, clearly states the requirements for residents with multidrug-resistant organisms. The policy mandates enhanced precautions for activities including "dressing, bathing, hygiene, changing briefs" — exactly the type of care both nursing assistants were providing.
Enhanced barrier precautions represent a critical infection control measure designed to prevent the spread of antibiotic-resistant bacteria between residents. These organisms pose particular dangers in nursing home settings, where residents often have compromised immune systems and share common spaces.
The inspection found that staff failed to follow basic safety protocols during the most vulnerable moments of resident care — when handling bodily waste and providing intimate hygiene assistance. Both incidents occurred during overnight shifts when supervision is typically reduced.
Klebsiella pneumoniae, the bacteria affecting Resident E, can cause severe pneumonia, bloodstream infections, and wound infections. When resistant to multiple antibiotics, it becomes extremely difficult to treat and can be life-threatening for elderly residents.
The violations occurred despite clear signage on residents' doors, written physician orders, and facility policies requiring the protective equipment. In both cases, the nursing assistants had access to the required gowns but chose not to use them.
One nursing assistant only donned the required gown after being stopped by an inspector and directed to read the isolation sign. The other admitted unfamiliarity with the policy despite working in a facility where such precautions are routine for residents with resistant infections.
The facility's failure to ensure proper protective equipment use puts both residents and staff at risk for infection transmission, particularly given that both incidents involved direct contact with bodily waste from residents carrying multidrug-resistant organisms.
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 aide walked back to the door, read the isolation sign she had ignored, and then put on the protective gear.
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.