Dyer Nursing & Rehab: Unnecessary Drug Violations - IN
CNA 1 responded to Resident E's call light at 4:52 a.m. on November 24. The resident needed her incontinence brief changed. A sign on the door clearly marked Contact Isolation and Enhanced Barrier Precautions required.
The assistant washed her hands and put on gloves. She gathered supplies and announced she was ready to start care. Only when stopped by an observer did CNA 1 walk back to the entry door, read the isolation sign, and put on a gown.
Resident E had been diagnosed with Klebsiella pneumoniae in her urine, a potentially dangerous bacteria that can resist multiple antibiotics. Her care plan from November 3 specifically required Enhanced Barrier Precautions. A physician's order the same day mandated gown and gloves for "high contact resident care activities."
The 83-year-old required maximum assistance for toileting and bathing and was occasionally incontinent of both bowel and bladder.
Seventeen minutes later, inspectors found another violation in the same hallway.
CNA 2 had just finished changing Resident L's soiled brief when inspectors entered the room at 5:09 a.m. The resident lay in bed with covers off, and a dirty brief sat in the waste basket. The nursing assistant wore gloves but no gown.
Both residents in the room required Enhanced Barrier Precautions, according to signs posted on the entry door.
When questioned, CNA 2 admitted she was "unsure of the facility's EBP policy" and then read the isolation sign on the door for the first time.
Resident L also had multidrug-resistant organisms in her urine. A physician's order from 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 completely dependent on staff for bathing, and was frequently incontinent of bowel and bladder.
The RN Nurse Consultant later explained that CNA 2 was a new employee still in orientation.
Dyer Nursing's own policy, updated in March 2024, explicitly required Enhanced Barrier Precautions for residents with any multidrug-resistant organisms. The protocol applied to dressing, bathing, hygiene, and changing briefs.
Both violations occurred during the most intimate and high-contact care activities outlined in facility policy.
Enhanced Barrier Precautions represent an escalated infection control measure beyond standard precautions. They're implemented when residents harbor organisms that resist multiple antibiotics and could spread to other vulnerable patients.
Klebsiella pneumoniae, the bacteria found in Resident E's urine, can cause serious infections including pneumonia, bloodstream infections, and meningitis. The organism has developed resistance to many commonly used antibiotics, making infections difficult to treat.
The facility's policy referenced federal guidance requiring gowns and gloves specifically because these organisms can survive on surfaces and transfer between patients through healthcare worker contact.
Federal inspectors documented the violations as causing "minimal harm or potential for actual harm." But the failures occurred during exactly the type of care most likely to spread resistant bacteria between residents.
Both residents required maximum or near-maximum assistance with toileting and hygiene, making them entirely dependent on staff following proper infection control protocols.
The inspection found that basic infection control training had failed. One nursing assistant forgot the requirements mid-task. Another admitted she didn't know the facility's policy for handling dangerous bacteria.
CNA 2's status as a new employee in orientation raises questions about how Dyer Nursing trains staff to recognize and respond to isolation precautions before they provide unsupervised patient care.
The violations suggest systemic problems beyond individual mistakes. Two different nursing assistants on the same shift failed to follow clearly posted precautions for residents with documented multidrug-resistant infections.
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.
CNA 1 responded to Resident E's call light at 4:52 a.m.
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.