Dyer Nursing and Rehabilitation Center

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to assistance with shaving, hair washing, checking for incontinence, oral care, nail care and providing assistance with eating for 14 of 16 residents reviewed for ADLs. (Residents F, G, B, P, Q, R, S, T, N, J, K, H, L, and M)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure adequate supervision was provided related to dining and diet orders for 6 of 6 residents reviewed for accident hazards. (Residents V, D, C, T, U, and E)

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure residents who were admitted with or re-admitted with pressure ulcers received a timely assessment and treatment orders for 2 of 6 residents reviewed for pressure ulcers. (Residents C and N)

Inspectors wroteBased on record review and interview, the facility failed to complete post dialysis vital signs and had no documented assessments of dialysis access site for 1 of 3 residents reviewed for dialysis. (Resident C)Finding Included:Resident C's record was reviewed on 3/2/26 at 2:00 p.m. Diagnoses included, but were not limited to, heart failure, end stage renal disease (renal failure), diabetes, and dependent on renal dialysis. The 1/22/26 Annual Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. The resident had impairment on both sides of the lower extremities and was on dialysis. A Care Plan, dated 6/4/24 and revised on 2/25/26, indicated the resident required dialysis related to renal failure. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed ensure residents who were dependent on staff for activities of daily living (ADL's) received bathing at least twice a week and failed to ensure a resident received incontinence care timely, for 3 of 3 residents reviewed for ADL assistance. (Residents C, B, and D)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, related to blood sugars not completed and medications not administered as ordered by a physician, for 1 of 3 residents reviewed for quality of care and receiving medications as ordered. (Resident G)

Inspectors wroteBased on record review and interview, the facility failed to ensure a urinalysis (UA) with culture and sensitivity (C&S) laboratory test was completed as ordered for 1 of 1 resident reviewed for laboratory testing. (Resident C)

Inspectors wroteBased on record review and interview, the facility failed to establish and/or maintain a system that accounted for, periodically reconciled, and ensured the disposition of all controlled drugs, related to lack of documentation of narcotic medication administration for 1 of 1 resident reviewed for misappropriation of property. (Resident M)

Inspectors wroteBased 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)

Inspectors wroteBased 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)

Inspectors wroteBased on record review, and interview, the facility failed to report Doppler ultrasound results to the physician in a timely manner resulting in delayed treatment for 1 of 3 residents reviewed for notification. (Resident D)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident's dignity was maintained related to food spillage on the clothing and a shirt raised up exposing the resident's back for 1 of 3 residents reviewed for dignity. (Resident E)

Inspectors wroteBased on record review and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to incontinence care for 1 of 3 residents reviewed for ADLs. (Resident E)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to assistance with meals, shaving, oral care, and providing showers and nail care for 12 of 14 residents reviewed for ADLs. (Residents E, K, O, B, M, G, F, H, L, N, P, and J)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure insulin was signed out as ordered for 2 of 5 residents reviewed for unnecessary medications. The facility also failed to ensure treatments for skin excoriation, skin tears, and bruises were ordered and the areas were assessed and monitored for 2 of 6 residents reviewed for non-pressure related skin conditions, signs and symptoms of edema were addressed for 1 of 1 resident reviewed for edema, and no assessment of lung sounds were documented and new orders put into place for 1 of 1 resident reviewed for a change in condition. (Residents S, T, R, Q, and F)

Inspectors wroteBased on observation and interview, the facility failed to ensure residents in the memory care unit were supervised during meals and while eating for 4 of 4 residents reviewed for supervision. (Residents 81, R, L, and 6)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to staff failing to disinfect multi-use equipment, perform hand hygiene after glove removal, medications touched with bare hands, hand hygiene not completed after direct resident contact, glucometers not disinfected after use for 1 of 1 glucometer observed, not donning personal protective equipment (PPE) for a resident in enhanced barrier precautions (EBP), not containing soiled linen, and the improper storage of personal care equipment during random infection control observations. (Residents 63, 25, 83, 72, and 10 )

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure each resident's dignity was maintained related to wearing a hospital gown while in bed during the day for 1 of 2 residents reviewed for dignity. (Resident 72)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were assessed to self-administer medications and oxygen therapy and had physician's orders to self-administer for 3 of 3 residents reviewed for self-administration of medication. (Residents 91, 105 and 30)

Inspectors wroteBased on record review and interview, the facility failed to ensure a PASARR (preadmission screening and resident review) was completed when a new mental health diagnoses was added for 1 of 1 resident reviewed for PASARR. (Resident 124)

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop a plan of care that was individualized to the needs of a bilateral amputee for 1 of 27 residents reviewed for care plans. (Resident P)

Inspectors wrote2. During an interview on 2/3/25 at 3:05 p.m., Resident 30 indicated he was trying to contact his sister to get his lab results because when the facility got the results, they gave them to his sister and not to him. The record for Resident 30 was reviewed on 2/5/25 at 10:09 a.m. Diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease), dementia, schizophrenia, and sleep apnea. The 12/1/24 Annual Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. The resident had lab testing completed on 1/28/25, 1/31/25, and 2/3/25. There was no documentation the resident was informed of his lab results. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident with a limited range of motion had a physician-ordered splint in place for 1 of 1 resident reviewed for range of motion. (Resident O)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents were assisted with meals and nutritional supplement consumption was recorded for residents with a history of weight loss for 2 of 4 residents reviewed for nutrition. (Residents R and 81)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure gastrostomy tube (a tube surgically inserted into the stomach that allows for the delivery of food and medication) placement was checked prior to medication administration, water flushes and medications were instilled via gravity, and documentation of gastrostomy tube care was completed for 2 of 3 residents reviewed for tube feeding. (Residents 72 and K)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure oxygen was at the correct flow rate for 3 of 3 residents reviewed for oxygen. (Residents T, G, and 30)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 3 of 8 residents observed during medication pass. Four errors were observed during 34 opportunities for errors during medication administration. This resulted in a medication error rate of 11.7% (Residents 72, 9, and 114)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a controlled substance was double locked at all times for 1 of 2 medication rooms observed. (West Unit)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident received routine dental services for 1 of 1 resident reviewed for dental services. (Resident J)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident received the necessary care and services related to medications not administered as ordered by the Physician, for 2 of 15 residents reviewed for quality of care. (Residents F and G)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident with pain was monitored and assessed, medication effectiveness was evaluated and non-pharmacological interventions were attempted prior to giving pain medication for 1 of 2 residents reviewed for injury of unknown origin. (Resident D)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's behavior plan of care was implemented related to a resident with dementia who was exhibiting challenging and aggressive behaviors, for 1 of 2 residents reviewed for abuse. (Resident E)

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were thoroughly and accurately documented related to pain medication administration for 1 of 2 residents reviewed for injury of unknown origin. (Resident D)

Inspectors wroteBased on record review and interview, the facility failed to ensure effective services were provided to a dependent resident at risk to develop pressure injuries, and Resident C developed a facility-acquired pressure injury on the sacrum that deteriorated and exhibited signs and symptoms of infection for 1 of 3 residents reviewed for pressure ulcers. This deficient practice resulted in Resident C experiencing a significant change in condition that required hospitalization for wound-related septic shock and surgical debridement of the wound. The immediate jeopardy began on 3/9/24, when the sacral area was found and not thoroughly assessed. Treatment and further interventions for prevention and healing of the DTI were not initiated. The Administrator, Director of Nursing, and the Nurse Consultant were notified of the immediate jeopardy at 4/5/24 at 9:34. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure adequate supervision was provided to Resident B during a sit to stand mechanical lift transfer. Resident B required two staff assistance with transfers and was transferred with one CNA and not placed in the correct position on the bed and slid out of the sit to stand transfer sling with her right arm caught in the sling, onto the floor. This resulted in a fracture of the right humeral neck (shoulder). The facility also failed to ensure a fall prevention intervention was in place, related to a call light not with in reach for 2 of 3 residents reviewed for falls. (Residents B and F)

Inspectors wroteBased on record review and interview, the facility failed to ensure a Resident's record was completed in a timely manner, related to a change in condition assessment not charted at the time of the change and then had late entries entered 9 days after the event, for 1 of 10 residents reviewed for medical records. (Resident C)

Inspectors wroteBased on observation, record review, and interview, the facility failed to determine self-administration of medications was appropriate for residents, related to medications left with the residents for self administration and no assessment to indicate the residents were appropriate for self administration of medications, for 2 of 2 residents observed with medications left in the room for administration. (Residents N and K)

Inspectors wroteBased on record review and interview, the facility failed to ensure the requirements for a resident initiated discharge were completed, related to documentation of the intent to discharge, lack of a discharge planning Care Plan, lack of a discussion with the resident or Responsible Party about the discharge, and lack of a Discharge Summary, for 1 of 3 residents reviewed for discharges from the facility. (Resident J)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident received treatment and care in accordance with professional standards, related to treatment, assessment, and documentation of a skin condition, for 1 of 3 residents reviewed for quality of care related to skin conditions. (Resident D)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the posted Nurse Staffing Information was up-to-date and current, related to a lack of facility census documented on the postings. This had the potential to affect all of the residents who resided in the facility for the month of February, 2024.

Inspectors wroteBased on record review and interview, the facility failed to initiate Care Plans related to psychotropic medications for 1 of 26 residents whose Care Plans were reviewed. (Resident 80)

Inspectors wroteBased on record review and interview, the facility failed to ensure care plan meetings were completed quarterly and/or included the resident, responsible party, and IDT (interdisciplinary team) members as required for 2 of 3 residents reviewed for care planning. (Residents 72 and 20)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure dependent residents received assistance with activities of daily living (ADL's) related to nail care and the removal of facial hair for 3 of 9 residents reviewed for ADL's. (Residents 88, B, and 20)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure treatments were obtained for non pressure ulcers, and bruises and sutures were assessed and monitored for 3 of 3 residents reviewed for skin conditions, and residents were assessed and monitored after falls for 1 of 3 residents reviewed for accidents. (Residents 51, 80 and 53)

Inspectors wroteBased on record review and interview, the facility failed to ensure residents with impaired vision received the necessary services for 1 of 2 residents reviewed for vision. (Resident 72)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure each resident received the necessary treatment and services to promote healing for pressure ulcers related to completing treatments as ordered for 1 of 2 residents reviewed for pressure ulcers. (Resident 216)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident with a history of falls was wearing the proper footwear to prevent further falls and/or injury for 1 of 3 residents reviewed for accidents. (Resident D)

Inspectors wroteBased on record review and interview, the facility failed to ensure the Registered Dietitian's (RD) recommendations were acted upon in a timely manner for a resident with a history of weight loss for 1 of 2 residents reviewed for nutrition. (Resident 52)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure oxygen was on and set at the correct flow rate, and tracheostomy care was completed as ordered by the Physician for 4 of 4 residents reviewed for respiratory care. (Residents 27, 6, 17, and 4)

Inspectors wroteBased on record review and interview, the facility failed to provide care according to the Care Plan to prevent injury for a resident with dementia and who was combative with care for 1 of 2 residents reviewed for dementia care. (Resident 52)

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were managed appropriately related to missed medications, the timing of medications, and no indication for the use of Morphine Sulfate for 2 of 5 residents reviewed for unnecessary medications (Residents D and B).

Inspectors wroteBased on record review and interview, the facility failed to ensure non-pharmacological interventions were attempted first before the administration of an anti-anxiety medication and the medication was documented on the Medication Administration Record (MAR) for 1 of 5 residents reviewed for unnecessary medications. (Resident D)

Inspectors wroteBased on observations, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented related to isolation precautions for 1 of 1 resident reviewed for antibiotic use. (Resident 59)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure food temperatures were monitored for each meal. This had the potential to affect the 100 residents who received their food from the kitchen. (The Main Kitchen)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was assessed and monitored prior to being sent to the hospital for a change in condition and hospice orders were followed as written for 1 of 3 residents reviewed for a change in condition and 1 of 1 residents reviewed for hospice. (Resident B)

Inspectors wroteBased on observation and interview, the facility failed to ensure food served to resident rooms was received hot for 1 of 2 units observed. This had the potential to affect the 56 residents who resided on that unit and received food from the kitchen. (East Unit)

Inspectors wroteBased on observation and interview, the facility failed to serve and prepare food under sanitary conditions related to dirty food equipment, steam tables, wire racks, standing fans, and standing mixer for 1 of 1 kitchens observed. This had the potential to affect the 116 residents who received food from the kitchen. (The Main Kitchen)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented, including those to prevent and/or contain COVID-19, related to ensuring hand hygiene was completed before and after glove removal. The facility also failed to ensure lancets were disposed of properly for 2 of 2 glucometers observed, personal protective equipment (PPE) was worn correctly during COVID-19 testing, masks were worn correctly, wash basins were stored correctly, and multi-use equipment was disinfected for random observations for infection control. (Residents 58, 90, 102, 82, 85, 41, and G)

Inspectors wroteBased on observation and interview, the facility failed to ensure the residents' environment as well as the kitchen area was clean and in good repair related to dirty floors, marred doors, lime build up, dirty heating unit covers, dirty baseboards, food build up on the baseboards, lime build up on pipes, dirty floor tile, and dirty transportation carts in 1 of 1 kitchen areas and on 3 of 4 units. (The Main Kitchen and East, West, and Memory Care Units)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents had Physician's Orders for medications and an assessment to self-administer their own medications for 2 of 2 residents reviewed for self-administration of medication. (Residents 32 and 38)

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were invited to their Care Plan conferences for 2 of 2 residents reviewed for care planning. (Residents 38 and D)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure dependent residents received help with Activities of Daily Living (ADLs) related to repositioning in bed, hair washed, and showers, for 2 of 9 residents reviewed for ADLs. (Residents D and B)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure areas of bruising were assessed and monitored for 1 of 4 residents reviewed for skin conditions, non-pressure related. (Resident E)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure splints were applied as ordered and range of motion was completed for 3 of 3 residents reviewed for limited range of motion (ROM). (Residents 1, 30, and 90)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure fall interventions were in place for residents with a history of falls with and without injury related to a floor mattress and non-slip socks for 3 of 4 residents reviewed for falls. (Residents E, F, and C)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with a urinary catheter received the necessary treatment and services related to completing catheter care as ordered for 2 of 2 residents reviewed for urinary catheters. (Residents J and 84)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure reweights were obtained, food consumption logs were completed and supplements were provided for residents with a history of weight loss for 2 of 4 residents reviewed for nutrition. (Residents H and B)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure gastrostomy tube placement was checked prior to administering medications and the water flush and medications were instilled via gravity for 1 of 1 gastrostomy tube medication administrations. (Resident 24)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident with complaints of pain received scheduled medication to relieve the pain for 1 of 3 residents reviewed for pain. (Resident J)

Inspectors wroteBased on record review and interview, the facility failed to ensure insulin was administered as ordered related to sliding scale insulin for 2 of 5 residents reviewed for unnecessary medications. (Residents G and J)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents did not receive unnecessary medications without adequate indications for use and prn (as needed) anti-anxiety medication were only administered after non-pharmaceutical interventions were attempted for 2 of 5 residents reviewed for unnecessary medications. (Residents G and F)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medication carts were locked when out of view on 1 of 3 units throughout the facility. (The [NAME] Unit)

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a resident with a nourishing and well-balanced diet and failed to provide special dietary needs for 1 of 3 residents reviewed for nutritional services. (Resident J)

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or responsible parties were offered the opportunity to receive or decline an influenza and pneumococcal immunization and provided education on the benefits and potential side effects of the immunizations for 2 of 5 residents reviewed for immunizations. (Residents D and 72)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident and/or their Responsible Party were notified in writing related to a transfer to the hospital for 5 of 6 residents reviewed for hospitalization. (Residents 1, 73, 110, 72, and 77)