Dyer Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Dyer Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Apr 5, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF760Apr 14, 2022

  Based on observation, record review and interview, the facility failed to ensure residents were free of any significant medication errors related to not receiving anticoagulant (blood thinner) medications which resulted in a re-hospitalization for pulmonary emboli (blood clots in lungs) and new onset cardiomegaly (enlarged heart) for 2 of 3 residents reviewed for anticoagulant use. (Residents F and R) The facility also failed to ensure insulin and intravenous (IV) antibiotics were administered for 2 of 4 residents reviewed for unnecessary medications. (Residents F and D) The immediate jeopardy began on 3/5/22 when the resident's anticoagulant was not delivered to the facility after admission from the hospital. […]

• Actual harm, isolatedF689Apr 5, 2024

  Based 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) Findings include: 1. During an interview on 4/1/24 at 8:52 a.m., Resident B was lying in bed with the head of the bed elevated. […]

• Actual harm, isolatedF692Feb 2, 2022

  Based on record review and interview, the facility failed to consistently monitor food and fluid intake for at risk residents which resulted in hospitalization for dehydration for 2 of 3 residents reviewed for a change in condition. (Residents D and H) Findings include: 1. The closed record for Resident D was reviewed on 2/1/22 at 8:53 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS) assessment, dated 11/3/21, indicated the resident had short and long term memory problems and was severely impaired for daily decision making. She needed extensive assistance with eating and received a mechanically altered diet. […]

• No harm, potential for more than minimal, widespreadF812Sep 21, 2023

  Based 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) Finding includes: On 9/20/23 at 10:02 a.m., a kitchen sanitation tour was completed with the Dietary Food Manager (DFM). The food temperature binder was reviewed at that time. The food temperature logs for August and September 2023 were lacking documentation for the following dates and meals: - No documentation of lunch temperatures on 8/21/23. - No documentation of breakfast or lunch temperatures on 8/23/23 and 9/5/23. - No documentation of dinner temperatures on 9/1/23. - No documentation of any food temperatures on 9/2 and 9/3/23. […]