Dyer Nursing And Rehabilitation Center
DYER NURSING AND REHABILITATION CENTER in DYER, IN — inspection on November 25, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During the shift she recalled there being two cards of Norco for Resident M.
She indicated that one card was full and the other was the card they were pulling medications from.
Resident M's medications were all available and given during her shift. RN 7 was interviewed by facility staff on 8/9/25.
The employee reported that she remembered receiving Resident M's Norco from pharmacy.
She recalled that there were still a few pills left in the current card, and she received 2 more cards from pharmacy.
She had placed them in the narcotic box. A Packing Slip Proof of Delivery, dated 7/29/25, indicated two hydrocodone-acetaminophen (Norco) tablets 7.5-325 milligram medication cards containing 21 pills each were delivered on 7/29/25. RN 7 signed on the signature page.
Resident M's record was reviewed on 11/25/25 at 12:56 p.m. A Physician's Order, dated 7/16/25, indicated hydrocodone-acetaminophen tablet 7.5-325 milligrams (mg) give 1 tablet by mouth three times a day for pain.The August 2025 Medication Administration Record (MAR) indicated the hydrocodone-acetaminophen 7.5-325 mg was not administered on 8/6/25 at 10:00 p.m., 8/7/25 at 10:00 p.m., and 8/8/25 at 2:00 p.m.
Each dose was marked 9 - other/see progress notes. On 8/7/25 at 2:00 p.m., the MAR was left blank.
There were no narcotic count sheets available for Resident M.
During an interview on 11/25/25 at 12:37 p.m., the Nurse Consultant indicated LPN 8 had worked and realized a medication card was missing since the last shift she worked.
The medication was not available in the narcotic box, so she went to pull the medication from the EDK, however the pharmacy told her that the medication had just been filled, and she was unable to pull the medication.
Once they were notified of the missing medication cards, they started to interview staff that had taken care of Resident M.
There were no identified problems with narcotics until the interviews occurred with LPN 8 and LPN 9. LPN 8 indicated when she arrived for her shift, there were no Norco medication cards in the cart.
When LPN 9 was interviewed she had said there were two medication cards in total in the narcotic box, and they belonged to another resident.
When LPN 9 was asked where Resident M's Norco pills were, she then changed her story and said there was a total of four medication cards in the box.
There was a full house sweep to determine if any other resident's medications were missing which included reviewing all of the narcotic count sheets.
The medication cards for Resident M were not in the narcotic box and the narcotic count sheet was also missing.
Both LPN 8 and LPN 9 were sent for drug testing. It appeared that LPN 9 had tampered with the urine test completed on 8/8/25 and had a rescheduled test again on 8/14/25.
Based off the inconsistency with LPN 9's interview and the appearance of her tampering with the drug test, she was then immediately terminated.
After this occurred, a new procedure was put into place.
During change of shift hand-off, the nursing staff must fill out a count sheet that now includes how many total cards are in the narcotic box as well as an actual count of the medication pills.
During a follow-up interview on 11/25/25 at 1:50 p.m., the Nurse Consultant indicated it was standard of care for the nursing staff to do a change of shift narcotic count and fill out the narcotic count sheet.
They did not have any policies related to narcotic counts.
The staff did not have a formal in-service for their nursing staff related to the new procedure of the narcotic count.
This citation relates to Intake 2593183. 3.1-25(b)(3)
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/25/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Dyer Nursing and Rehabilitation Center
601 Sheffield Ave Dyer, IN 46311
SUMMARY STATEMENT OF DEFICIENCIES
Based on record review and interview, the facility failed to ensure a resident's blood pressure was monitored per Physician's Orders, for a resident who was receiving multiple medications for hypertension. (Resident B)Finding includes:Resident B's record was reviewed on 11/24/25 at 9:56 a.m.
The diagnoses included, but were not limited to, hypertensive heart disease and chronic kidney disease.The following Physician's Orders indicated medications that affect the blood pressure:8/20/25, spironolactone (anti-hypertensive/heart failure medication) 50 milligrams (mg) daily.8/29/25, midodrine (treatment of orthostatic hypotension) 5 mg three times a day for major side effect systolic supine hypertension.8/29/25, a Physician's Order indicated vital signs were to be checked every shift.9/2/25, metoprolol tartrate (beta-blocker to treat hypertension) 25 mg twice a day.9/4/25, bumetanide (diuretic) 1 mg twice a day.The Medication Administration Record, dated 11/2025, indicated the vital signs had not been ochecked every shift as ordered by the physician.
During an interview, on 11/25/25 at 12:18 p.m., the Director of Nursing indicated the order had not been transcribed to the Medication Administration Record.A facility medication administration policy, dated 10/2014 and received as current from the RN Nurse Consultant, indicated, .Monitoring of side effects or medication-related problems occurs continually.This citation relates to Intake 2617694.3.1-48(a)(3)
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/25/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Dyer Nursing and Rehabilitation Center
601 Sheffield Ave Dyer, IN 46311
SUMMARY STATEMENT OF DEFICIENCIES
Based on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members (CNA 1 and CNA 2) when providing care to residents who were in Enhanced Barrier Precautions (EBP) and Contact Isolation, for 2 random observations. (Residents E and L) Findings include: 1.
During an observation on 11/24/25 at 4:52 a.m., CNA 1 responded to Resident E's call light and the resident indicated she needed her incontinence brief changed.
There was a sign on the outside of the entry door that indicated Contact Isolation and EBP precautions were required.
CNA 1 completed hand hygiene, applied gloves and prepared the supplies for the care.
She indicated she was ready to start the care and was stopped prior to the administration of care. CNA 1 walked to the entry door and observed the sign on the door and then donned a gown.
Resident E's record was reviewed on 11/25/25 at 10:32 a.m.
The diagnoses included, but were not limited to, diabetes mellitus, urinary tract infection (UTI), and Klebsiella Pneumoniae (bacteria). An admission Minimum Data Set (MDS) assessment, dated 10/24/25, indicated maximum assistance was required for toileting and bathing and she was occasionally incontinent of bowel and bladder. A Care Plan, dated 11/3/25, indicated EBP for Klebsiella Pneumoniae was required.
The interventions indicated the facility protocol for EBP would be followed. A Physician's Order, dated 11/3/25, indicated EBP was required due to Klebsiella Pneumoniae in the urine. A gown and gloves were to be used for high contact resident care activities. 2.
During an observation on 11/24/25 at 5:09 a.m., CNA 2 was in Resident's L room.
The resident was lying in bed and the covers were off the resident. CNA 2 indicated she had just completed incontinence care and there was a soiled brief in the waste basket. CNA 2 was wearing gloves but no gown.
The entry door had a sign that indicated both residents of the room required EBP. CNA 2 indicated she was unsure of the facility's EBP policy and then read the EBP sign on the door.Resident L's record was reviewed on 11/25/25 at 11:59 a.m.
The diagnoses included, but were not limited to, spinal stenosis and urinary tract infection.An Annual MDS assessment, dated 10/3/25, indicated maximum assistance was required for toileting and bed mobility, was dependent on staff for bathing, and moderate assistance was required for hygiene.
The resident was frequently incontinent of bowel and bladder.A Physician's Order, dated 11/12/25, indicated EBP was required related to multidrug-resistance organisms (MDROs)in the urine.
Gown and gloves were required for high contact resident care activities.
During an interview on 11/25/25 at 2:18 p.m., the RN Nurse Consultant indicated CNA 2 was a new employee and was still in orientation.A facility EBP policy (Centers for Clinical Standards and Quality, Safety & Oversight Group Memorandum.
Reference: QSP-24-08-NH), dated 3/2024 and received from the RN Nurse Consultant as current, indicated EBP was required for residents with any MDROs. EBP was to be for, but not limited to, dressing, bathing, hygiene, changing briefs.3.1-18(b)
Facility ID: